Provider Demographics
NPI:1255394136
Name:LAKE HOSPITAL SYSTEM
Entity type:Organization
Organization Name:LAKE HOSPITAL SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
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:440-354-1990
Mailing Address - Street 1:PO BOX 714031
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-4031
Mailing Address - Country:US
Mailing Address - Phone:440-716-1283
Mailing Address - Fax:440-716-1605
Practice Address - Street 1:36000 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4625
Practice Address - Country:US
Practice Address - Phone:440-953-6082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHLA3600981Medicare ID - Type Unspecified