Provider Demographics
NPI:1205896404
Name:LAKE HOSPITAL SYSTEM, INC
Entity type:Organization
Organization Name:LAKE HOSPITAL SYSTEM, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:TRACZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-354-1952
Mailing Address - Street 1:PO BOX 781348
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1348
Mailing Address - Country:US
Mailing Address - Phone:800-354-1985
Mailing Address - Fax:
Practice Address - Street 1:7956 TYLER BLVD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4806
Practice Address - Country:US
Practice Address - Phone:440-255-6400
Practice Address - Fax:440-255-3637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH264200000OtherFEDERAL BLACK LUNG
OH6600162OtherUNITED HEALTHCARE
OH2440175Medicaid
OH264200000OtherDEPT OF LABOR
OH2017301Medicaid
OH=========042OtherMEDICAL MUTUAL OF OHIO
OH=========005OtherTRICARE
OH2017301Medicaid
OH=========10OtherWORKERS COMP
OH=========005OtherTRICARE