MEDICARE: SUTTER LAKESIDE HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	282NR1301X	Rural Acute Care Hospital	010000118	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	050476	OTHER	CA	MEDICARE PROVIDER NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HSP13994F	OTHER		HAP
2	ZZZC1701Z	OTHER		BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	CGP127375	OTHER	CA	CHILDREN SERVICES
6	050476	OTHER		BLUE CROSS
7	C083612	OTHER		CHAMPVA
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063407229
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUTTER LAKESIDE HOSPITAL

Provider Business Mailing Address
First Line	:	5176 HILL RD E
Second Line	:
City	:	LAKEPORT
State	:	CA
Zip	:	95453-6300
Country	:	US
Telephone Number	:	707-262-5181
Fax Number	:	707-262-5006

Provider Business Practice Location Address
First Line	:	5176 HILL RD E
Second Line	:
City	:	LAKEPORT
State	:	CA
Zip	:	95453-6300
Country	:	US
Telephone Number	:	707-262-5181
Fax Number	:	707-262-5006

Authorized Official
Title or Position	:	CEO
Name	:	MRS. KELLY MATHER
Credential	:	CEO
Telephone Number	:	707-262-5001

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	07/31/2008

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Directions to “SUTTER LAKESIDE HOSPITAL ” Practice Location

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