Provider Demographics
NPI:1003807835
Name:LAKEVIEW SURGERY CENTER LC
Entity Type:Organization
Organization Name:LAKEVIEW SURGERY CENTER LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD CHAIR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:MOHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:515-270-5240
Mailing Address - Street 1:1750 60TH STREET
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266
Mailing Address - Country:US
Mailing Address - Phone:515-273-5240
Mailing Address - Fax:515-273-5241
Practice Address - Street 1:1750 60TH STREET
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266
Practice Address - Country:US
Practice Address - Phone:515-273-5240
Practice Address - Fax:515-273-5241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-01
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA261QA1903X
261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0610089Medicaid
IA61002OtherBLUE SHIELD PROVIDER NUMB
IA0610089Medicaid