Healthcare Provider Details

I. General information

NPI: 1417267410
Provider Name (Legal Business Name): LAKEVIEW MEDICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2010
Last Update Date: 10/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4868 BRIDGE RD
SUFFOLK VA
23435-2048
US

IV. Provider business mailing address

2000 MEADE PKWY
SUFFOLK VA
23434-4259
US

V. Phone/Fax

Practice location:
  • Phone: 757-483-7900
  • Fax: 757-483-7164
Mailing address:
  • Phone: 757-539-0251
  • Fax: 757-934-9497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number215137
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number215137
License Number StateVA

VIII. Authorized Official

Name: MICHAEL B STOUT
Title or Position: CEO
Credential:
Phone: 757-539-0251