Provider Demographics
NPI:1851698435
Name:LAKE HOSPITAL SYSTEM INC
Entity Type:Organization
Organization Name:LAKE HOSPITAL SYSTEM INC
Other - Org Name:LAKE HEALTH ALLIED HEALTH PROFESSIONALS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:EBEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-375-8100
Mailing Address - Street 1:PO BOX 781789
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1789
Mailing Address - Country:US
Mailing Address - Phone:440-375-8100
Mailing Address - Fax:
Practice Address - Street 1:7590 AUBURN RD
Practice Address - Street 2:
Practice Address - City:CONCORD TWP
Practice Address - State:OH
Practice Address - Zip Code:44077-9176
Practice Address - Country:US
Practice Address - Phone:440-375-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE HOSPITAL SYSTEM INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-17
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty