NPIMap

Organization Active NPI

South Lake Clinic, PA

  • Pediatrics Physician
  • Minnetonka, MN
National Provider Identifier
1871924191
Registry record updated Aug 29, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
SOUTH LAKE CLINIC, PA
Practice address
6060 Clearwater Dr Ste 240
Minnetonka, MN 55343-9468
Phone
(952) 401-8300
Fax
(952) 401-8243
NPI assigned
Dec 12, 2013
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 29, 2023

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

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208000000X Primary

Addresses

Primary practice location

6060 Clearwater Dr Ste 240
Minnetonka, MN 55343-9468

Mailing address

17705 Hutchins Dr Ste 250
Minnetonka, MN 55345-4103
Phone (952) 401-8300

Other names 1

  • South Lake Pediatrics Doing business as

National Provider Directory

National Provider Directory
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.

NPI Registry JSON

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": "1871924191",
    "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": "6060 CLEARWATER DR STE 240",
            "city": "MINNETONKA",
            "state": "MN",
            "postal_code": "553439468",
            "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"
        }
    ]
}

Other providers in Minnetonka, MN

Sources for this page

  • 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.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.