Provider Demographics
NPI:1164697629
Name:LAKE HOSPITAL SYSTEM INC
Entity Type:Organization
Organization Name:LAKE HOSPITAL SYSTEM INC
Other - Org Name:PRIMEHEALTH INTERNAL MEDICINE WILLOUGHBY HILLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
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:440-354-1642
Mailing Address - Street 1:10 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-3460
Mailing Address - Country:US
Mailing Address - Phone:440-354-1642
Mailing Address - Fax:440-354-1994
Practice Address - Street 1:2747 SOM CENTER RD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-9164
Practice Address - Country:US
Practice Address - Phone:440-354-1899
Practice Address - Fax:440-354-1089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty