Basic Information
| Provider Information | |||||||||
| NPI: | 1902088024 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKES REGION UROLOGY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 85 SPRING ST | ||||||||
| Address2: | |||||||||
| City: | LACONIA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032463113 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 85 SPRING ST | ||||||||
| Address2: | |||||||||
| City: | LACONIA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032463113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035248660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2007 | ||||||||
| LastUpdateDate: | 11/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | DUMONT | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 6035248660 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | NH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 00000655 | 05 | NH | MEDICAID |