MEDICARE: CHARLES WILLIAM LAIS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	29597	MN

General Provider Information

NPI Number	:	1053387456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES WILLIAM LAIS MD

Provider Business Mailing Address
First Line	:	8100 34TH AVE S
Second Line	:	21110Q
City	:	BLOOMINGTON
State	:	MN
Zip	:	55425-1672
Country	:	US
Telephone Number	:	952-883-5790
Fax Number	:	952-883-5395

Provider Business Practice Location Address
First Line	:	530 3RD ST NW
Second Line	:	MAIL STOP 39400A
City	:	ELK RIVER
State	:	MN
Zip	:	55330-1445
Country	:	US
Telephone Number	:	763-712-6000
Fax Number	:	763-712-6591

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2006
Last Update Date	:	07/08/2007

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Directions to “ CHARLES WILLIAM LAIS MD” Practice Location

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