Basic Information
Provider Information | |||||||||
NPI: | 1649598012 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LRGHEALTHCARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LAKES REGION UROLOGY AMBULATORY SURGICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1327 | ||||||||
Address2: |   | ||||||||
City: | LACONIA | ||||||||
State: | NH | ||||||||
PostalCode: | 032471327 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6035243211 | ||||||||
FaxNumber: | 6035277038 | ||||||||
Practice Location | |||||||||
Address1: | 85 SPRING ST | ||||||||
Address2: | SUITE 302 | ||||||||
City: | LACONIA | ||||||||
State: | NH | ||||||||
PostalCode: | 032463169 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6035248660 | ||||||||
FaxNumber: | 6035286220 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2010 | ||||||||
LastUpdateDate: | 05/11/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LIPMAN | ||||||||
AuthorizedOfficialFirstName: | HENRY | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | EVP-CFO | ||||||||
AuthorizedOfficialTelephone: | 6035272802 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | LRGHEALTHCARE | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 03021 | NH | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.