Basic Information
| Provider Information | |||||||||
| NPI: | 1851698435 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKE HOSPITAL SYSTEM INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKE HEALTH ALLIED HEALTH PROFESSIONALS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 781789 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403758100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7590 AUBURN RD | ||||||||
| Address2: | |||||||||
| City: | CONCORD TWP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440779176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403758100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2011 | ||||||||
| LastUpdateDate: | 04/04/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EBEL | ||||||||
| AuthorizedOfficialFirstName: | DAVE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CFO | ||||||||
| AuthorizedOfficialTelephone: | 4403758100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAKE HOSPITAL SYSTEM INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364S00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 363A00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.