Healthcare Provider Details

I. General information

NPI: 1689634966
Provider Name (Legal Business Name): LAKE HOSPITAL SYSTEM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 02/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 5TH AVE
CHARDON OH
44024-1077
US

IV. Provider business mailing address

PO BOX 781348
DETROIT MI
48278-4110
US

V. Phone/Fax

Practice location:
  • Phone: 440-286-8908
  • Fax: 440-257-1527
Mailing address:
  • Phone: 440-286-8908
  • Fax: 440-279-1527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT TRACZ
Title or Position: CFO
Credential:
Phone: 440-354-1952