Healthcare Provider Details

I. General information

NPI: 1326141987
Provider Name (Legal Business Name): LAKE HOSPITAL SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29804 LAKESHORE BLVD
WILLOWICK OH
44095
US

IV. Provider business mailing address

PO BOX 714328
COLUMBUS OH
43271-4328
US

V. Phone/Fax

Practice location:
  • Phone: 440-833-2095
  • Fax: 440-833-2096
Mailing address:
  • Phone: 800-354-1985
  • 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 Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-084193
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35-084193
License Number State

VIII. Authorized Official

Name: MR. ROBERT TRACZ
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 440-354-1051