MEDICARE: LAKE HOSPITAL SYSTEM, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207R00000X	Internal Medicine Physician
2	208D00000X	General Practice Physician
3	207Q00000X	Family Medicine Physician
4	261QU0200X	Urgent Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	264200002	OTHER	OH	FEDERAL BLACK LUNG
2	6600162	OTHER	OH	UNITED HEALTHCARE
3	264200002	OTHER	OH	DEPT OF LABOR
4	80507	OTHER	OH	QUALCHOICE
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134189376
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE HOSPITAL SYSTEM, INC

Provider Business Mailing Address
First Line	:	PO BOX 781348
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48278-4110
Country	:	US
Telephone Number	:	800-354-1985
Fax Number	:

Provider Business Practice Location Address
First Line	:	6270 N RIDGE RD
Second Line	:
City	:	MADISON
State	:	OH
Zip	:	44057-2567
Country	:	US
Telephone Number	:	440-428-8256
Fax Number	:	440-417-0020

Authorized Official
Title or Position	:	CFO
Name	:	MR. ROBERT TRACZ
Credential	:
Telephone Number	:	440-354-1953

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	02/15/2017

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Directions to “LAKE HOSPITAL SYSTEM, INC ” Practice Location

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