South Lake Clinic, PA

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

Legal business name

SOUTH LAKE CLINIC, PA

Doing business as

South Lake Pediatrics

Practice address

12000 Elm Creek Blvd N Ste 250
Maple Grove, MN 55369-7164

Phone

(952) 401-8300

Fax

(952) 401-8243

NPI assigned

Dec 12, 2013

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Heidi Northrup, MHA

Title

Administrator

Phone

(952) 401-8300

Specialties & licenses 1

Addresses

Other names 1

• South Lake Pediatrics Doing business as

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Tax ID family

South Lake Clinic PA5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

• South Lake Clinic, P.a.

  dba South Lake Pediatrics

  • Pediatrics Physician
  • Minnetonka, MN
  • NPI 1427027184
  NPD tax ID
• South Lake Clinic, PA

  dba South Lake Pediatrics

  • Pediatrics Physician
  • Plymouth, MN
  • NPI 1689005902
  NPD tax ID
• South Lake Clinic, PA

  dba South Lake Pediatrics

  • Pediatrics Physician
  • Chaska, MN
  • NPI 1780015008
  NPD tax ID
• South Lake Clinic, PA

  dba South Lake Pediatrics

  • Pediatrics Physician
  • Minnetonka, MN
  • NPI 1871924191
  NPD tax ID

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1386806400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1693267200000",
    "number": "1770914095",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17705 HUTCHINS DR STE 250",
            "city": "MINNETONKA",
            "state": "MN",
            "postal_code": "553454103",
            "telephone_number": "952-401-8300",
            "fax_number": "952-401-8240"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12000 ELM CREEK BLVD N STE 250",
            "city": "MAPLE GROVE",
            "state": "MN",
            "postal_code": "553697164",
            "telephone_number": "952-401-8300",
            "fax_number": "952-401-8243"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH LAKE CLINIC, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-12-12",
        "last_updated": "2023-08-29",
        "certification_date": "2023-08-29",
        "status": "A",
        "authorized_official_last_name": "NORTHRUP",
        "authorized_official_first_name": "HEIDI",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "952-401-8300",
        "authorized_official_credential": "MHA"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "South Lake Pediatrics",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "South Lake Pediatrics",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Pediatrics Physician in Maple Grove, MN
• Providers in Maple Grove, MN by specialty
• Pediatrics Physician in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 29, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.