1689634966 NPI number — LAKE HOSPITAL SYSTEM, INC

Table of content: (NPI 1689634966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689634966 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:
1689634966
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2017
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:
48278-4110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-286-8908
Provider Business Mailing Address Fax Number:
440-279-1527

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 5TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARDON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44024-1077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-286-8908
Provider Business Practice Location Address Fax Number:
440-257-1527
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: 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: 207Q00000X ; 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: 264200003 . This is a "DEPT OF LABOR" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 264200003 . This is a "FEDERAL BLACK LUNG" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2475352 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6600162 . This is a "UNITED HEALTHCARE" 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: 80507 . This is a "QUALCHOICE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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