Provider Demographics
NPI:1942580394
Name:LAKE HOSPITAL SYSTEM
Entity Type:Organization
Organization Name:LAKE HOSPITAL SYSTEM
Other - Org Name:LHPG THOMAS MENTOR FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:CICERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-354-1739
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:440-205-8818
Mailing Address - Fax:440-974-1794
Practice Address - Street 1:8316 YELLOWBRICK RD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4960
Practice Address - Country:US
Practice Address - Phone:440-205-8818
Practice Address - Fax:440-974-1794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty