Basic Information
| Provider Information | |||||||||
| NPI: | 1932796992 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKEVIEW MEDICAL CENTER, INC. OF RICE LAKE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1700 W STOUT ST | ||||||||
| Address2: | |||||||||
| City: | RICE LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548685000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152368100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1700 W STOUT ST | ||||||||
| Address2: | |||||||||
| City: | RICE LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548685000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152368100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2020 | ||||||||
| LastUpdateDate: | 12/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EDWARDS | ||||||||
| AuthorizedOfficialFirstName: | GORDON | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO/COO | ||||||||
| AuthorizedOfficialTelephone: | 7153875823 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARSHFIELD CLINIC HEALTH SYSTEMS | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.