Provider Demographics
NPI:1124255278
Name:LAKE HOSPITAL SYSTEM, INC.
Entity type:Organization
Organization Name:LAKE HOSPITAL SYSTEM, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VP, BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
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:440-354-1899
Mailing Address - Fax:440-354-1089
Practice Address - Street 1:36001 EUCLID AVE
Practice Address - Street 2:B-3
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4643
Practice Address - Country:US
Practice Address - Phone:440-953-1898
Practice Address - Fax:440-953-9296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-16
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty