Provider Demographics
NPI:1629089875
Name:SUTTER LAKESIDE HOSPITAL
Entity Type:Organization
Organization Name:SUTTER LAKESIDE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-262-5001
Mailing Address - Street 1:5176 HILL RD E
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-6300
Mailing Address - Country:US
Mailing Address - Phone:707-262-5000
Mailing Address - Fax:707-262-5018
Practice Address - Street 1:5176 HILL RD E
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6300
Practice Address - Country:US
Practice Address - Phone:707-262-5000
Practice Address - Fax:707-262-5018
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUTTER LAKESIDE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-11
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05Z329Medicare Oscar/Certification
CA05U476Medicare ID - Type UnspecifiedSNF/SWING