Organization
LAKE UROLOGY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
VICKI ORR (BILLER)
(219) 836-6241
Entity
Organization
Contact information
Practice address
929 RIDGE RD STE 1, MUNSTER, IN 46321-1769
(219) 836-6241
(219) 836-2433
Mailing address
PO BOX 3060, MUNSTER, IN 46321-0060
(219) 836-6241
(219) 836-2433
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
01036410A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200981370A
—
IN
01
—
DQ2352
RR MEDICARE
IN
Enumeration date
03/13/2008
Last updated
09/14/2010
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