MEDICARE: SILVER LAKE CLINIC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1053347179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SILVER LAKE CLINIC

Provider Business Mailing Address
First Line	:	2600 39TH AVE NE
Second Line	:
City	:	ST ANTHONY
State	:	MN
Zip	:	55421-4372
Country	:	US
Telephone Number	:	612-706-2900
Fax Number	:	612-706-2901

Provider Business Practice Location Address
First Line	:	2600 39TH AVE NE
Second Line	:
City	:	ST ANTHONY
State	:	MN
Zip	:	55421-4372
Country	:	US
Telephone Number	:	612-706-2900
Fax Number	:	612-706-2901

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER, VP FINANCE
Name	:	MR. PATRICK BORAN
Credential	:
Telephone Number	:	763-520-5048

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	08/22/2020

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Directions to “SILVER LAKE CLINIC ” Practice Location

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