MEDICARE: LOLA B SUTHERLAND MD

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	207Q00000X	Family Medicine Physician	MN26313	MN
2	207Q00000X	Family Medicine Physician	26313	MN

General Provider Information

NPI Number	:	1417924994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOLA B SUTHERLAND MD

Provider Business Mailing Address
First Line	:	1200 SIXTH AVE NO
Second Line	:	CENTRA CARE CLINIC
City	:	SAINT CLOUD
State	:	MN
Zip	:	56303
Country	:	US
Telephone Number	:	763-263-7300
Fax Number	:

Provider Business Practice Location Address
First Line	:	16830 198TH AVE NW
Second Line	:	BIG LAKE CLINIC
City	:	BIG LAKE
State	:	MN
Zip	:	55309
Country	:	US
Telephone Number	:	763-263-7300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2006
Last Update Date	:	12/05/2007

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