Healthcare Provider Details

I. General information

NPI: 1710295829
Provider Name (Legal Business Name): LAKE HOSPITAL SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2010
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36100 EUCLID AVE SUITE 400
WILLOUGHBY OH
44094-4456
US

IV. Provider business mailing address

PO BOX 714328
COLUMBUS OH
43271-4328
US

V. Phone/Fax

Practice location:
  • Phone: 440-602-6735
  • Fax: 440-946-3221
Mailing address:
  • Phone: 440-602-6735
  • Fax: 440-946-3221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT TRACZ
Title or Position: CFO
Credential:
Phone: 440-354-1642