Provider Demographics
NPI:1225264146
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:440-354-1055
Mailing Address - Street 1:36000 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-4625
Mailing Address - Country:US
Mailing Address - Phone:440-953-9600
Mailing Address - Fax:440-953-6081
Practice Address - Street 1:36000 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4625
Practice Address - Country:US
Practice Address - Phone:440-953-9600
Practice Address - Fax:440-953-6081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-05
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
36S098OtherPTAN