Provider Demographics
NPI:1053140822
Name:NORTHERN LAKES SURGERY CENTER, LLC
Entity type:Organization
Organization Name:NORTHERN LAKES SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ROBERT REES
Authorized Official - Last Name:LYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-758-0719
Mailing Address - Street 1:8552 N GOVERNMENT WAY
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9280
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8552 N GOVERNMENT WAY
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9280
Practice Address - Country:US
Practice Address - Phone:208-457-4211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty