Basic Information
| Provider Information | |||||||||
| NPI: | 1639134158 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE REGIONAL MEDICAL MANAGEMENT, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKE REGIONAL MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 54 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650653050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733022840 | ||||||||
| FaxNumber: | 5733022841 | ||||||||
| Practice Location | |||||||||
| Address1: | 54 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650653050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733488074 | ||||||||
| FaxNumber: | 5733488069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 08/26/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ZEISEL | ||||||||
| AuthorizedOfficialFirstName: | HENRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXEC V.P. CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5733488388 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 501945604 | 05 | MO | MEDICAID |