Organization
LAKE HOSPITAL SYSTEM, INC
Active
Other names
Lake Health Urgent Care and Walk In Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ROBERT TRACZ (CFO)
(440) 354-1952
Entity
Organization
Contact information
Practice address
510 5TH AVE, CHARDON, OH 44024-1077
(440) 286-8908
(440) 257-1527
Mailing address
PO BOX 781348, DETROIT, MI 48278-4110
(440) 286-8908
(440) 279-1527
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
—
—
207R00000X
Internal Medicine Physician
—
—
208D00000X
General Practice Physician
—
—
261QU0200X
Urgent Care Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2017301
—
OH
05
—
2475352
—
OH
01
—
264200003
DEPT OF LABOR
OH
01
—
6600162
UNITED HEALTHCARE
OH
01
—
80507
QUALCHOICE
OH
Enumeration date
03/23/2006
Last updated
02/17/2017
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