Basic Information
| Provider Information | |||||||||
| NPI: | 1538138003 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKEVIEW MEMORIAL HOSPITAL ASSOCIATION INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKEVIEW HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 310 | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550820310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514304581 | ||||||||
| FaxNumber: | 6514304528 | ||||||||
| Practice Location | |||||||||
| Address1: | 927 CHURCHILL ST W | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550826605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514304529 | ||||||||
| FaxNumber: | 6514304528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 01/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6514304581 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAKEVIEW MEMORIAL HOSPITAL ASSOCIATION INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 330771 | MN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 41 | 01 | MN | HEALTHPARTNERS | OTHER | 01006069 | 01 | MN | PERFERRED ONE | OTHER | 300064 | 01 | MN | UCARE MINNESOTA | OTHER | 11005400 | 05 | WI | MEDICAID | 5012806 | 01 | MN | MEDICA CHOICE INSTUTIONAL | OTHER | 834547300 | 05 | MN | MEDICAID | 1005491 | 01 | MN | PREFERRED ONE (PEAK) | OTHER | 1874HLA | 01 | MN | MINNESOTA BLUE CROSS | OTHER | 8005491 | 01 | MN | PREFERRED COM HEALTH PLAN | OTHER |