Healthcare Provider Details

I. General information

NPI: 1518264043
Provider Name (Legal Business Name): LAKE HOSPITAL SYSTEM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2011
Last Update Date: 06/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SUCCESS BLVD
PERRY OH
44081-9404
US

IV. Provider business mailing address

PO BOX 714328
COLUMBUS OH
43271-4328
US

V. Phone/Fax

Practice location:
  • Phone: 440-375-8590
  • Fax: 440-259-2106
Mailing address:
  • Phone: 440-354-1985
  • Fax: 440-350-4938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL KITTOE
Title or Position: CFO
Credential:
Phone: 440-354-1085