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General NPI Number Information
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NPI Number | 1134189376
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Entity Type | Organization
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Legal Business Name | LAKE HOSPITAL SYSTEM, INC
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Dates
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Enumeration Date | 03/23/2006
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Last Update Date | 02/15/2017
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Provider Practice Location Address
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Address Line | 6270 N RIDGE RD
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City | MADISON
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State | OH
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Zip | 44057-2567
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Country | US
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Telephone | 440-428-8256
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Fax | 440-417-0020
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Provider Business Mailing Address
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Address Line | PO BOX 781348
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City | DETROIT
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State | MI
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Zip | 48278-4110
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Country | US
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Telephone | 800-354-1985
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Fax |
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Authorized Official
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Title or Position | CFO
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Name | MR. ROBERT TRACZ
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Credential |
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Telephone | 440-354-1953
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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