Basic Information
| Provider Information | |||||||||
| NPI: | 1881823151 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BASTROP BLACKHAWK LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKESIDE HOSPITAL AT BASTROP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3201 HIGHWAY 71 E | ||||||||
| Address2: | |||||||||
| City: | BASTROP | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786025126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123218200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3201 HIGHWAY 71 E | ||||||||
| Address2: | |||||||||
| City: | BASTROP | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786025126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123218200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2009 | ||||||||
| LastUpdateDate: | 11/23/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BIEDERMAN | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5126813440 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 282N00000X | 008314 | TX | Y | Hospitals | General Acute Care Hospital |
No ID Information.