Basic Information
| Provider Information | |||||||||
| NPI: | 1669609756 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE HOSPITAL SYSTEM, INC. | ||||||||
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| OtherOrganizationName: | LAKE HEALTH PHYSICIAN GROUP VASCULAR ACCESS SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 20050 HARVARD AVE | ||||||||
| Address2: | |||||||||
| City: | WARRENSVILLE HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441226816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409531898 | ||||||||
| FaxNumber: | 4409539296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2009 | ||||||||
| LastUpdateDate: | 12/29/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 06/08/2011 | ||||||||
| NPIReactivationDate: | 12/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | HOGYA | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALNG ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 4403541899 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.