Provider Demographics
NPI:1184868879
Name:ST LUKE'S LAKESIDE HOSPITAL, LLC
Entity type:Organization
Organization Name:ST LUKE'S LAKESIDE HOSPITAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:LIPHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-266-2030
Mailing Address - Street 1:17400 ST. LUKE'S WAY
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77384
Mailing Address - Country:US
Mailing Address - Phone:936-266-4055
Mailing Address - Fax:936-266-4051
Practice Address - Street 1:17400 ST. LUKE'S WAY
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77384
Practice Address - Country:US
Practice Address - Phone:936-266-4055
Practice Address - Fax:936-266-4051
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST LUKE'S HEALTH SYSTEM,
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-24
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160630301Medicaid
TX160630301Medicaid