Provider Demographics
NPI:1821114729
Name:LAKEVIEW MEMORIAL HOSPITAL ASSOCIATION INC.
Entity Type:Organization
Organization Name:LAKEVIEW MEMORIAL HOSPITAL ASSOCIATION INC.
Other - Org Name:LAKEVIEW HOSPITAL PHYSICIANS
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-430-4581
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-0310
Mailing Address - Country:US
Mailing Address - Phone:651-430-4529
Mailing Address - Fax:651-430-4528
Practice Address - Street 1:927 CHURCHILL ST W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6605
Practice Address - Country:US
Practice Address - Phone:651-430-4529
Practice Address - Fax:651-430-4528
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKEVIEW MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-22
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X, 207RH0003X
MN365380363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatalGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN300064OtherUCARE
MN56697TEOtherBLUE CROSS MN
MN110674OtherHEALTHPARTNERS
WI32889100Medicaid
MN834547300Medicaid
MN65247OtherPREFERRED ONE
MNC63317OtherMEDICARE RAILROAD
MN3946489OtherMEDICA CHOICE
MN834547300Medicaid
MNC00078Medicare PIN