Provider Demographics
NPI:1134171366
Name:LAKE NORMAN UROLOGY PLLC
Entity type:Organization
Organization Name:LAKE NORMAN UROLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMIN
Authorized Official - Prefix:MS
Authorized Official - First Name:G
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:HAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-660-3322
Mailing Address - Street 1:137 PROFESSIONAL PARK DRIVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8522
Mailing Address - Country:US
Mailing Address - Phone:704-660-3322
Mailing Address - Fax:704-660-3330
Practice Address - Street 1:137 PROFESSIONAL PARK DRIVE
Practice Address - Street 2:SUITE D
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8522
Practice Address - Country:US
Practice Address - Phone:704-660-3322
Practice Address - Fax:704-660-3330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790279RMedicaid
NC2327866Medicare ID - Type UnspecifiedGROUP PRICING NUMBER