Basic Information
| Provider Information | |||||||||
| NPI: | 1316198724 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE HOSPITAL SYSTEM, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 714328 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432714328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403541899 | ||||||||
| FaxNumber: | 4403541089 | ||||||||
| Practice Location | |||||||||
| Address1: | 7580 AUBURN ROAD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CONCORD TOWNSHIP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403520400 | ||||||||
| FaxNumber: | 4403524535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2008 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | TRACZ | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4403541642 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAKE HOSPITAL SYSTEM, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | LA9368241 | 01 | OH | MEDICARE PTAN | OTHER |