Provider Demographics
NPI:1316198724
Name:LAKE HOSPITAL SYSTEM, INC.
Entity Type:Organization
Organization Name:LAKE HOSPITAL SYSTEM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:TRACZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-354-1642
Mailing Address - Street 1:PO BOX 714328
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-4328
Mailing Address - Country:US
Mailing Address - Phone:440-354-1899
Mailing Address - Fax:440-354-1089
Practice Address - Street 1:7580 AUBURN ROAD
Practice Address - Street 2:SUITE 202
Practice Address - City:CONCORD TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:44077
Practice Address - Country:US
Practice Address - Phone:440-352-0400
Practice Address - Fax:440-352-4535
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE HOSPITAL SYSTEM, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHLA9368241OtherMEDICARE PTAN