Provider Demographics
NPI:1063407229
Name:SUTTER LAKESIDE HOSPITAL
Entity type:Organization
Organization Name:SUTTER LAKESIDE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHER
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:707-262-5001
Mailing Address - Street 1:5176 HILL RD E
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-6300
Mailing Address - Country:US
Mailing Address - Phone:707-262-5181
Mailing Address - Fax:707-262-5006
Practice Address - Street 1:5176 HILL RD E
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6300
Practice Address - Country:US
Practice Address - Phone:707-262-5181
Practice Address - Fax:707-262-5006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA010000118282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
HSP13994FOtherHAP
ZZZC1701ZOtherBLUE SHIELD
CAHSP40476FMedicaid
CA050476OtherMEDICARE PROVIDER NUMBER
CACGP127375OtherCHILDREN SERVICES
050476OtherBLUE CROSS
C083612OtherCHAMPVA
CAZZR00476FMedicaid
CAZZR00476FMedicaid