1821114729 NPI number — LAKEVIEW MEMORIAL HOSPITAL ASSOCIATION INC.

Table of content: (NPI 1821114729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821114729 NPI number — LAKEVIEW MEMORIAL HOSPITAL ASSOCIATION INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEVIEW MEMORIAL HOSPITAL ASSOCIATION INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LAKEVIEW HOSPITAL PHYSICIANS
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821114729
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STILLWATER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55082-0310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-430-4529
Provider Business Mailing Address Fax Number:
651-430-4528

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
927 CHURCHILL ST W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STILLWATER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55082-6605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-430-4529
Provider Business Practice Location Address Fax Number:
651-430-4528
Provider Enumeration Date:
03/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
651-430-4581

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LN0000X , with the licence number: 365380 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 300064 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 56697TE . This is a "BLUE CROSS MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 110674 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 32889100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 834547300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 65247 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: C63317 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 3946489 . This is a "MEDICA CHOICE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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