MEDICARE: LAKE HOSPITAL SYSTEM INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207Q00000X	Family Medicine Physician
2	207R00000X	Internal Medicine Physician
3	208D00000X	General Practice Physician
4	261QU0200X	Urgent Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	264200001	OTHER	OH	DEPT OF LABOR
2	80507	OTHER	OH	QUALCHOICE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	264200001	OTHER	OH	FEDERAL BLACK LUNG
5	6600162	OTHER	OH	UNITED HEALTHCARE
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912967209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE HOSPITAL SYSTEM INC.

Provider Business Mailing Address
First Line	:	PO BOX 781348
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48278-1348
Country	:	US
Telephone Number	:	800-354-1895
Fax Number	:	440-585-1962

Provider Business Practice Location Address
First Line	:	29804 LAKE SHORE BLVD
Second Line	:
City	:	WILLOWICK
State	:	OH
Zip	:	44095-4611
Country	:	US
Telephone Number	:	440-585-3322
Fax Number	:	440-585-1962

Authorized Official
Title or Position	:	CFO
Name	:	MR. BOB TRACZ
Credential	:
Telephone Number	:	440-354-1953

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	02/15/2017

Similar Medicare Providers

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1255264867 — TIANA SIMINGTON
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1811987852 — DR. GARY ALLEN CRUM D.C.
Practice Location Address:

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Directions to “LAKE HOSPITAL SYSTEM INC. ” Practice Location

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