Provider Demographics
NPI:1699000281
Name:LAKE HOSPITAL SYSTEM, INC
Entity Type:Organization
Organization Name:LAKE HOSPITAL SYSTEM, INC
Other - Org Name:LAKE HEALTH WALK IN CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
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:48278-1348
Mailing Address - Country:US
Mailing Address - Phone:440-354-3887
Mailing Address - Fax:440-354-4071
Practice Address - Street 1:74 S PARK PLACE
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077
Practice Address - Country:US
Practice Address - Phone:440-354-3887
Practice Address - Fax:440-354-4071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-15
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2017301Medicaid
OH2017301Medicaid