Provider Demographics
NPI:1720020274
Name:LAKE HOSPITAL SYSTEM INC
Entity Type:Organization
Organization Name:LAKE HOSPITAL SYSTEM INC
Other - Org Name:PRIMEHEALTH PEDIATRICS WILLOUGHBY
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:
Authorized Official - Last Name:TRACZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-354-1051
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:800-354-1985
Mailing Address - Fax:440-350-4938
Practice Address - Street 1:36001 EUCLID AVE
Practice Address - Street 2:STE B-16
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094
Practice Address - Country:US
Practice Address - Phone:440-942-4844
Practice Address - Fax:440-918-4627
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE HOSPITAL SYSTEM, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-11
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2017338Medicaid
OH2017338Medicaid