MEDICARE: LAKE HARBOR INTERNAL MEDICINE ASSOC LLC

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	207R00000X	Internal Medicine Physician	M6886	ID

General Provider Information

NPI Number	:	1851430995
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE HARBOR INTERNAL MEDICINE ASSOC LLC

Provider Business Mailing Address
First Line	:	3684 NORTH HARBOR LANE
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83703-6914
Country	:	US
Telephone Number	:	208-853-4556
Fax Number	:	208-853-5544

Provider Business Practice Location Address
First Line	:	3684 NORTH HARBOR LANE
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83703-6914
Country	:	US
Telephone Number	:	208-853-4556
Fax Number	:	208-853-5544

Authorized Official
Title or Position	:	OWNER PHYSICIAN
Name	:	KERI ERLAND
Credential	:	MD
Telephone Number	:	208-853-4556

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	08/22/2020

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