Healthcare Provider Details

I. General information

NPI: 1851698435
Provider Name (Legal Business Name): LAKE HOSPITAL SYSTEM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7590 AUBURN RD
CONCORD TWP OH
44077-9176
US

IV. Provider business mailing address

PO BOX 781789
DETROIT MI
48278-1789
US

V. Phone/Fax

Practice location:
  • Phone: 440-375-8100
  • Fax:
Mailing address:
  • Phone: 440-375-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DAVE EBEL
Title or Position: INTERIM CFO
Credential:
Phone: 440-375-8100