Healthcare Provider Details

I. General information

NPI: 1669783593
Provider Name (Legal Business Name): LAKE HOSPITAL SYSTEM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7956 TYLER BLVD
MENTOR OH
44060-4806
US

IV. Provider business mailing address

PO BOX 714328
COLUMBUS OH
43271-4328
US

V. Phone/Fax

Practice location:
  • Phone: 440-833-2010
  • Fax: 440-833-2096
Mailing address:
  • Phone: 440-833-2020
  • Fax: 440-833-2096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT B TRACZ
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 440-354-1642