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	License Number	License Number State
1	207QS0010X	Sports Medicine (Family Medicine) Physician

General Provider Information

NPI Number	:	1639315062
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE HOSPITAL SYSTEM, INC.

Provider Business Mailing Address
First Line	:	PO BOX 714328
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43271-4328
Country	:	US
Telephone Number	:	800-354-1985
Fax Number	:	440-350-4938

Provider Business Practice Location Address
First Line	:	29804 LAKESHORE BLVD
Second Line	:
City	:	WILLOWICK
State	:	OH
Zip	:	44095-4611
Country	:	US
Telephone Number	:	440-354-1899
Fax Number	:	440-354-1089

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	ROBERT TRACZ
Credential	:
Telephone Number	:	440-354-1642

Provider Enumeration Date	:	01/07/2009
Last Update Date	:	01/07/2009

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