Provider Demographics
NPI:1881823151
Name:BASTROP BLACKHAWK LLC
Entity Type:Organization
Organization Name:BASTROP BLACKHAWK LLC
Other - Org Name:LAKESIDE HOSPITAL AT BASTROP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:F
Authorized Official - Last Name:BIEDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-681-3440
Mailing Address - Street 1:3201 HIGHWAY 71 E
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-5126
Mailing Address - Country:US
Mailing Address - Phone:512-321-8200
Mailing Address - Fax:
Practice Address - Street 1:3201 HIGHWAY 71 E
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-5126
Practice Address - Country:US
Practice Address - Phone:512-321-8200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-08
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
TX008314282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A4959Medicare PIN
TX670011Medicare Oscar/Certification