Basic Information
| Provider Information | |||||||||
| NPI: | 1821114729 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKEVIEW MEMORIAL HOSPITAL ASSOCIATION INC. | ||||||||
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| OtherOrganizationName: | LAKEVIEW HOSPITAL PHYSICIANS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 310 | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550820310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514304529 | ||||||||
| 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: | 03/22/2007 | ||||||||
| LastUpdateDate: | 01/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6514304581 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAKEVIEW MEMORIAL HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207RH0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 363LN0000X | 365380 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
ID Information
| ID | Type | State | Issuer | Description | 300064 | 01 | MN | UCARE | OTHER | 56697TE | 01 | MN | BLUE CROSS MN | OTHER | 110674 | 01 | MN | HEALTHPARTNERS | OTHER | 32889100 | 05 | WI | MEDICAID | 834547300 | 05 | MN | MEDICAID | 65247 | 01 | MN | PREFERRED ONE | OTHER | C63317 | 01 | MN | MEDICARE RAILROAD | OTHER | 3946489 | 01 | MN | MEDICA CHOICE | OTHER |