Basic Information
| Provider Information | |||||||||
| NPI: | 1053581454 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE REGIONAL HEALTH SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 54 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650653050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733488074 | ||||||||
| FaxNumber: | 5733488069 | ||||||||
| Practice Location | |||||||||
| Address1: | 54 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650653050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733488000 | ||||||||
| FaxNumber: | 5733488069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2008 | ||||||||
| LastUpdateDate: | 08/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | HALSELL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. V.P., CFO/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 5733488388 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 291-30 | MO | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207PE0004X | 291-30 | MO | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 540671609 | 05 | MO | MEDICAID |