=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164661005
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKEWALK IMAGING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2009
-----------------------------------------------------
Last Update Date | 02/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1502 LONDON ROAD
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55812-1788
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-730-2165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1502 LONDON ROAD SUITE 101
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55812-1788
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANDREW BAERTSCH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 218-730-2165
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------