# LAKE HOSPITAL SYSTEM, INC.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Lake Health Physician Group Vascular Access Surgery
- **Organization subpart:** No

## Provider details

- **NPI number:** 1124255278
- **Authorized official:** RICHARD D CICERO (SR. VP, BUSINESS DEVELOPMENT)
- **Authorized official phone:** (440) 354-1739

## Contact information

- **Practice address:** 36001 EUCLID AVE, B-3, WILLOUGHBY, OH 44094-4643
- **Practice address phone:** (440) 953-1898
- **Practice address fax:** (440) 953-9296
- **Mailing address:** PO BOX 714328, COLUMBUS, OH 43271-4328
- **Mailing address phone:** (440) 354-1899
- **Mailing address fax:** (440) 354-1089

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208600000X | Surgery Physician | — | NULL | — |
| 208600000X | Surgery Physician | — | — | — |
| 2086S0129X | Vascular Surgery Physician | — | NULL | Yes |
| 2086S0129X | Vascular Surgery Physician | — | — | Yes |

## Other

- **Enumeration date:** 06/16/2009
- **Last updated:** 04/25/2011