Provider Demographics
NPI:1477844686
Name:LAKE HOSPITAL SYSTEM, INC.
Entity Type:Organization
Organization Name:LAKE HOSPITAL SYSTEM, INC.
Other - Org Name:LAKE HEALTH PHYSICIAN GROUP MENTOR GENERAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP, BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:CICERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-354-1739
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:440-354-0377
Mailing Address - Fax:440-354-9368
Practice Address - Street 1:9500 MENTOR AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-8713
Practice Address - Country:US
Practice Address - Phone:440-354-0377
Practice Address - Fax:440-354-9368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty