Provider Demographics
NPI:1710207329
Name:LAKE HOSPITAL SYSTEM, INC.
Entity Type:Organization
Organization Name:LAKE HOSPITAL SYSTEM, INC.
Other - Org Name:LAKE HEALTH PHYSICIAN GROUP OB/GYN
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:B
Authorized Official - Last Name:TRACZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-354-1642
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:440-205-5862
Mailing Address - Fax:440-205-5861
Practice Address - Street 1:9485 MENTOR AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4597
Practice Address - Country:US
Practice Address - Phone:440-205-5862
Practice Address - Fax:440-205-5861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty