Basic Information
| Provider Information | |||||||||
| NPI: | 1639170699 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKESIDE WOMEN'S HOSPITAL, LLC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11200 N PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731205045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059861500 | ||||||||
| FaxNumber: | 4059361579 | ||||||||
| Practice Location | |||||||||
| Address1: | 11200 N PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731205045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059861500 | ||||||||
| FaxNumber: | 4059361579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 07/02/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WEED | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SYSTEM VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4059512737 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 2339 | OK | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000370199001 | 01 | OK | BCBS | OTHER | 100745350B | 05 | OK | MEDICAID | 100745350A | 05 | OK | MEDICAID |