1124255278 NPI number — LAKE HOSPITAL SYSTEM, INC.

Table of content: (NPI 1124255278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124255278 NPI number — LAKE HOSPITAL SYSTEM, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE HOSPITAL SYSTEM, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LAKE HEALTH PHYSICIAN GROUP VASCULAR ACCESS SURGERY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124255278
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 714328
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43271-4328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-354-1899
Provider Business Mailing Address Fax Number:
440-354-1089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36001 EUCLID AVE
Provider Second Line Business Practice Location Address:
B-3
Provider Business Practice Location Address City Name:
WILLOUGHBY
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44094-4643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-953-1898
Provider Business Practice Location Address Fax Number:
440-953-9296
Provider Enumeration Date:
06/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CICERO
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
D
Authorized Official Title or Position:
SR. VP, BUSINESS DEVELOPMENT
Authorized Official Telephone Number:
440-354-1739

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com