Basic Information
| Provider Information | |||||||||
| NPI: | 1336291160 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKES REGIONAL HEALTHCARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTHWEST IOWA EMERGENCY PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2301 HIGHWAY 71 SOUTH | ||||||||
| Address2: | PO BOX AB | ||||||||
| City: | SPIRIT LAKE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 513600159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123361230 | ||||||||
| FaxNumber: | 7123368634 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 HIGHWAY 71 SOUTH | ||||||||
| Address2: | |||||||||
| City: | SPIRIT LAKE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 51360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123361230 | ||||||||
| FaxNumber: | 7123368634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 09/07/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALGER | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR VP AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 7123368796 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAKES REGIONAL HEALTHCARE | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 300028H | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0250738 | 05 | IA | MEDICAID | 19398NW | 01 | IA | BCBS MN GROUP PHYSICIAN | OTHER | 25073 | 01 | IA | BCBS IA GROUP PHYSICIAN | OTHER |