Provider Demographics
NPI:1295719714
Name:LAKE SUPERIOR INTERNAL MEDICINE
Entity type:Organization
Organization Name:LAKE SUPERIOR INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:PEARCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-727-0080
Mailing Address - Street 1:324 W SUPERIOR ST
Mailing Address - Street 2:SUITE 625
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1701
Mailing Address - Country:US
Mailing Address - Phone:218-727-0080
Mailing Address - Fax:218-727-2322
Practice Address - Street 1:324 W SUPERIOR ST
Practice Address - Street 2:SUITE 625
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1701
Practice Address - Country:US
Practice Address - Phone:218-727-0080
Practice Address - Fax:218-727-2322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31798207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNE58171Medicare UPIN