Provider Demographics
NPI:1588156657
Name:SAGE MEDICAL PROF LLC
Entity type:Organization
Organization Name:SAGE MEDICAL PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:LAURICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-430-9340
Mailing Address - Street 1:345 W STEAMBOAT DR STE 701
Mailing Address - Street 2:
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5287
Mailing Address - Country:US
Mailing Address - Phone:319-430-9340
Mailing Address - Fax:
Practice Address - Street 1:345 W STEAMBOAT DR STE 701
Practice Address - Street 2:
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049-5287
Practice Address - Country:US
Practice Address - Phone:319-430-9340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7960OtherSTATE LICENSE