Provider Demographics
NPI:1962642694
Name:LAKES RADIOLOGY PLLC
Entity Type:Organization
Organization Name:LAKES RADIOLOGY PLLC
Other - Org Name:CENTRAL AUBURN IMAGING LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-944-1665
Mailing Address - Street 1:1626 CLARK STREET ROAD
Mailing Address - Street 2:SUITE 18
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021
Mailing Address - Country:US
Mailing Address - Phone:315-252-9462
Mailing Address - Fax:315-252-9466
Practice Address - Street 1:1626 CLARK STREET ROAD
Practice Address - Street 2:SUITE 18
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021
Practice Address - Country:US
Practice Address - Phone:315-252-9462
Practice Address - Fax:315-252-9466
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKES RADIOLOGY PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-20
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
J100000227Medicare PIN