Provider Demographics
NPI:1881621761
Name:CENTRAL LAKES MEDICAL CLINIC PA
Entity type:Organization
Organization Name:CENTRAL LAKES MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-546-2501
Mailing Address - Street 1:318 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1691
Mailing Address - Country:US
Mailing Address - Phone:218-546-8375
Mailing Address - Fax:218-546-4400
Practice Address - Street 1:318 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1691
Practice Address - Country:US
Practice Address - Phone:218-546-8375
Practice Address - Fax:218-546-4400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1160207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN088208900Medicaid
MN08289Medicare PIN
MN0603250001Medicare NSC