Provider Demographics
NPI:1518264043
Name:LAKE HOSPITAL SYSTEM INC
Entity Type:Organization
Organization Name:LAKE HOSPITAL SYSTEM INC
Other - Org Name:PRIME HEALTH PERRY HEALTH AND WELLNESS
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KITTOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-354-1085
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:440-354-1985
Mailing Address - Fax:440-350-4938
Practice Address - Street 1:2 SUCCESS BLVD
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:OH
Practice Address - Zip Code:44081-9404
Practice Address - Country:US
Practice Address - Phone:440-375-8590
Practice Address - Fax:440-259-2106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-18
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2925964Medicaid