1205896404 NPI number — LAKE HOSPITAL SYSTEM, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205896404 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:
Provider Other Organization Name Type Code:
6
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:
1205896404
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:
800-354-1985
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7956 TYLER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENTOR
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44060-4806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-255-6400
Provider Business Practice Location Address Fax Number:
440-255-3637
Provider Enumeration Date:
03/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TRACZ
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
440-354-1952

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 264200000 . 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: 2440175 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 264200000 . This is a "DEPT OF LABOR" 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".




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