Healthcare Provider Details

I. General information

NPI: 1043275837
Provider Name (Legal Business Name): LAKE HOSPITAL SYSTEM INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/21/2022
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 781348
DETROIT MI
48278
US

V. Phone/Fax

Practice location:
  • Phone: 440-375-8152
  • Fax: 440-354-1245
Mailing address:
  • Phone: 800-354-1985
  • Fax: 440-354-4938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT TRACZ
Title or Position: CFO
Credential:
Phone: 440-354-1051