1912967209 NPI number — LAKE HOSPITAL SYSTEM INC.

Table of content: (NPI 1912967209)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912967209 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 URGENT CARE AND WALK IN CENTER
Provider Other Organization Name Type Code:
5
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:
1912967209
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29804 LAKE SHORE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLOWICK
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44095-4611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-585-3322
Provider Business Practice Location Address Fax Number:
440-585-1962
Provider Enumeration Date:
03/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TRACZ
Authorized Official First Name:
BOB
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
440-354-1953

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 264200001 . This is a "DEPT OF LABOR" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 80507 . This is a "QUALCHOICE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2017301 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 264200001 . This is a "FEDERAL BLACK LUNG" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 6600162 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2440148 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com