Provider Demographics
NPI:1043275837
Name:LAKE HOSPITAL SYSTEM INC.
Entity Type:Organization
Organization Name:LAKE HOSPITAL SYSTEM INC.
Other - Org Name:
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:440-354-1051
Mailing Address - Street 1:PO BOX 781348
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278
Mailing Address - Country:US
Mailing Address - Phone:800-354-1985
Mailing Address - Fax:440-354-4938
Practice Address - Street 1:7590 AUBURN RD
Practice Address - Street 2:
Practice Address - City:CONCORD TWP
Practice Address - State:OH
Practice Address - Zip Code:44077-9176
Practice Address - Country:US
Practice Address - Phone:440-375-8152
Practice Address - Fax:440-354-1245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHLA3600981Medicare ID - Type Unspecified
OH4922507Medicaid
OHLA3600981Medicare ID - Type Unspecified