Provider Demographics
NPI:1689634966
Name:LAKE HOSPITAL SYSTEM, INC
Entity Type:Organization
Organization Name:LAKE HOSPITAL SYSTEM, INC
Other - Org Name:LAKE HEALTH URGENT CARE AND WALK IN CLINIC
Other - Org Type:Doing Business As
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:440-354-1952
Mailing Address - Street 1:PO BOX 781348
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-4110
Mailing Address - Country:US
Mailing Address - Phone:440-286-8908
Mailing Address - Fax:440-279-1527
Practice Address - Street 1:510 5TH AVE
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-1077
Practice Address - Country:US
Practice Address - Phone:440-286-8908
Practice Address - Fax:440-257-1527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH264200003OtherDEPT OF LABOR
OH264200003OtherFEDERAL BLACK LUNG
OH2475352Medicaid
OH6600162OtherUNITED HEALTHCARE
OH2017301Medicaid
OH80507OtherQUALCHOICE
OH264200003OtherFEDERAL BLACK LUNG
OH6600162OtherUNITED HEALTHCARE
OH=========043OtherMEDICAL MUTUAL OF OHIO
OH2475352Medicaid