Provider Demographics
NPI:1326141987
Name:LAKE HOSPITAL SYSTEM
Entity Type:Organization
Organization Name:LAKE HOSPITAL SYSTEM
Other - Org Name:PRIMEHEALTH WILLOWICK PRIMARY CARE
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:440-354-1051
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:800-354-1985
Mailing Address - Fax:440-350-4938
Practice Address - Street 1:29804 LAKESHORE BLVD
Practice Address - Street 2:
Practice Address - City:WILLOWICK
Practice Address - State:OH
Practice Address - Zip Code:44095
Practice Address - Country:US
Practice Address - Phone:440-833-2095
Practice Address - Fax:440-833-2096
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE HOSPITAL SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-07
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
OH35-084193207R00000X
35-084193208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2694259Medicaid
OH2694259Medicaid