Provider Demographics
NPI:1912967209
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:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:TRACZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-354-1953
Mailing Address - Street 1:PO BOX 781348
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1348
Mailing Address - Country:US
Mailing Address - Phone:800-354-1895
Mailing Address - Fax:440-585-1962
Practice Address - Street 1:29804 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:WILLOWICK
Practice Address - State:OH
Practice Address - Zip Code:44095-4611
Practice Address - Country:US
Practice Address - Phone:440-585-3322
Practice Address - Fax:440-585-1962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH264200001OtherDEPT OF LABOR
OH80507OtherQUALCHOICE
OH2017301Medicaid
OH264200001OtherFEDERAL BLACK LUNG
OH6600162OtherUNITED HEALTHCARE
OH2440148Medicaid
OH=========09OtherWORKERS COMP
OH=========006OtherTRICARE
OH2017301Medicaid
OHDA3964Medicare ID - Type UnspecifiedRAILROAD