Provider Demographics
NPI:1932246923
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:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:GARRETT
Authorized Official - Last Name:RUBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-834-7345
Mailing Address - Street 1:325 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-1300
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:2007-01-31
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN739045900Medicaid
MN50326LAOtherBLUE CROSS MINNESOTA
MN3940403OtherMEDICA
MN300411OtherUCARE
MN01016526OtherPREFERRED ONE
MN2718OtherHEALTHPARTNERS