Provider Demographics
NPI:1295811313
Name:LAKEVIEW MEMORIAL HOSPITAL ASSN, INC
Entity type:Organization
Organization Name:LAKEVIEW MEMORIAL HOSPITAL ASSN, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:927 CHURCHILL ST W
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6605
Mailing Address - Country:US
Mailing Address - Phone:651-439-5330
Mailing Address - Fax:651-430-8540
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:651-430-4562
Practice Address - Fax:651-430-8540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN200202-2333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33218600Medicaid
MN194023600Medicaid
MN241225-7OtherNABP NUMBER
MN0945820001Medicare NSC