Organization
SOUTH LAKE CLINIC, PA
Active
Other names
South Lake Pediatrics
Organization subpart
No
Provider details
NPI number
Authorized official
HEIDI NORTHRUP MHA (ADMINISTRATOR)
(952) 401-8300
Entity
Organization
Contact information
Practice address
12000 ELM CREEK BLVD N STE 250, MAPLE GROVE, MN 55369-7164
(952) 401-8300
(952) 401-8243
Mailing address
17705 HUTCHINS DR STE 250, MINNETONKA, MN 55345-4103
(952) 401-8300
(952) 401-8240
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
—
—
Other
Enumeration date
12/12/2013
Last updated
08/29/2023
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