Provider Demographics
NPI:1831213644
Name:LAKEVIEW MEDICAL CLINIC
Entity type:Organization
Organization Name:LAKEVIEW MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:J
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:320-352-6591
Mailing Address - Street 1:433 ELM STREET NORTH
Mailing Address - Street 2:
Mailing Address - City:SAUK CENTRE
Mailing Address - State:MN
Mailing Address - Zip Code:56378
Mailing Address - Country:US
Mailing Address - Phone:320-352-6591
Mailing Address - Fax:
Practice Address - Street 1:433 ELM ST N
Practice Address - Street 2:
Practice Address - City:SAUK CENTRE
Practice Address - State:MN
Practice Address - Zip Code:56378-1052
Practice Address - Country:US
Practice Address - Phone:320-352-6591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1425261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN54033LAOtherBCBS OF MN
MNC07555Medicare ID - Type UnspecifiedMEDICARE CLINIC