Basic Information
| Provider Information | |||||||||
| NPI: | 1053347179 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SILVER LAKE CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 39TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | ST ANTHONY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554214372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127062900 | ||||||||
| FaxNumber: | 6127062901 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 39TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | ST ANTHONY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554214372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127062900 | ||||||||
| FaxNumber: | 6127062901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BORAN | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER, VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7635205048 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.