Basic Information
| Provider Information | |||||||||
| NPI: | 1881621761 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL LAKES MEDICAL CLINIC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 318 EAST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | CROSBY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564411691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185468375 | ||||||||
| FaxNumber: | 2185464400 | ||||||||
| Practice Location | |||||||||
| Address1: | 318 EAST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | CROSBY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564411691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185468375 | ||||||||
| FaxNumber: | 2185464400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 10/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2185462501 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1160 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 088208900 | 05 | MN | MEDICAID |