=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992946891
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROOKED LAKE FAMILY MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2009
-----------------------------------------------------
Last Update Date | 03/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1930 PRE EMPTION RD
-----------------------------------------------------
City | PENN YAN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14527-9641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-536-0086
-----------------------------------------------------
Fax | 315-536-4107
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1077
-----------------------------------------------------
City | GENEVA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14456-8077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-536-0086
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LISA WALK-REINARD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 315-536-0086
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 209529
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------