Provider Demographics
NPI:1023067642
Name:LAKE VIEW MEMORIAL HOSPITAL, INC
Entity type:Organization
Organization Name:LAKE VIEW MEMORIAL HOSPITAL, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP & CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-847-2526
Mailing Address - Street 1:29980 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1299
Mailing Address - Country:US
Mailing Address - Phone:218-834-7300
Mailing Address - Fax:218-834-7388
Practice Address - Street 1:325 11TH AVE
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1300
Practice Address - Country:US
Practice Address - Phone:218-834-7300
Practice Address - Fax:218-834-7388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RG0100X
MN331064282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN739045900Medicaid
MN1886HLAOtherBLUE CROSS MINNESOTA
2718OtherHEALTHPARTNERS
5000116OtherMEDICA
MNUCAREOtherUCARE MINNESOTA
MN01016526OtherPREFERRED ONE