MEDICARE: LAKES REGION SURGICAL ASSOCIATES, PC

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	208600000X	Surgery Physician		NH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033289269
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKES REGION SURGICAL ASSOCIATES, PC

Provider Business Mailing Address
First Line	:	PO BOX 1328
Second Line	:
City	:	AUBURN
State	:	ME
Zip	:	04211-1328
Country	:	US
Telephone Number	:	207-784-9185
Fax Number	:	207-784-1594

Provider Business Practice Location Address
First Line	:	25 COUNTRY CLUB RD
Second Line	:	VILLAGE WEST, BUILDING 7
City	:	GILFORD
State	:	NH
Zip	:	03249-6972
Country	:	US
Telephone Number	:	603-528-1547
Fax Number	:	603-524-5536

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	NICOLA SHAFIQUE
Credential	:
Telephone Number	:	603-528-1547

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	07/21/2022

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