Healthcare Provider Details

I. General information

NPI: 1770914095
Provider Name (Legal Business Name): SOUTH LAKE CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 ELM CREEK BLVD N STE 250
MAPLE GROVE MN
55369-7164
US

IV. Provider business mailing address

17705 HUTCHINS DR STE 250
MINNETONKA MN
55345-4103
US

V. Phone/Fax

Practice location:
  • Phone: 952-401-8300
  • Fax: 952-401-8243
Mailing address:
  • Phone: 952-401-8300
  • Fax: 952-401-8240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: HEIDI NORTHRUP
Title or Position: ADMINISTRATOR
Credential: MHA
Phone: 952-401-8300