Provider Demographics
NPI:1609273259
Name:LAKE REGIONAL MEDICAL MANAGEMENT, INC.
Entity Type:Organization
Organization Name:LAKE REGIONAL MEDICAL MANAGEMENT, INC.
Other - Org Name:LAKE REGIONAL UROLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-348-8756
Mailing Address - Street 1:PO BOX 801661
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1661
Mailing Address - Country:US
Mailing Address - Phone:573-348-8000
Mailing Address - Fax:
Practice Address - Street 1:1075 NICHOLS RD
Practice Address - Street 2:SUITE 7-8
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3093
Practice Address - Country:US
Practice Address - Phone:573-302-3111
Practice Address - Fax:573-302-2869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-25
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1609273259Medicaid
MO3928520003Medicare Oscar/Certification