# LAKE UROLOGY LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1720259146
- **Authorized official:** VICKI ORR (BILLER)
- **Authorized official phone:** (219) 836-6241

## Contact information

- **Practice address:** 929 RIDGE RD STE 1, MUNSTER, IN 46321-1769
- **Practice address phone:** (219) 836-6241
- **Practice address fax:** (219) 836-2433
- **Mailing address:** PO BOX 3060, MUNSTER, IN 46321-0060
- **Mailing address phone:** (219) 836-6241
- **Mailing address fax:** (219) 836-2433

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208800000X | Urology Physician | 01036410A | IN | Yes |

## Other

- **Enumeration date:** 03/13/2008
- **Last updated:** 09/14/2010

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 200981370A | — | IN |
| 01 | — | DQ2352 | RR MEDICARE | IN |