1285698878 NPI number — LAKESIDE MEDICAL CENTER, INC.

Table of content: (NPI 1285698878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285698878 NPI number — LAKESIDE MEDICAL CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE MEDICAL CENTER, 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:
Provider Other Organization Name Type Code:
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:
1285698878
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
129 6TH AVE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINE CITY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55063-1913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-629-2542
Provider Business Mailing Address Fax Number:
320-629-1093

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
129 6TH AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINE CITY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55063-1913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-629-2542
Provider Business Practice Location Address Fax Number:
320-629-1093
Provider Enumeration Date:
04/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCMAHON
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
320-629-2542

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  330908 , 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: 5017321 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0694HLA . This is a "BLUECROSS BLUESHEILD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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