NPIMap

Organization Active NPI

Lake Hospital System Inc

  • Pediatrics Physician
  • Mentor, OH
National Provider Identifier
1013951920
Registry record updated Sep 6, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
LAKE HOSPITAL SYSTEM INC
Practice address
9485 Mentor Ave
101
Mentor, OH 44060
Phone
(440) 205-5800
Fax
(440) 205-5801
NPI assigned
Jun 15, 2006
Organization subpart
Yes
Parent organization
LAKE HOSPITAL SYSTEM, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 6, 2007

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Robert Tracz
Title
Chief Financial Officer
Phone
(440) 354-1051

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208000000X Primary

Addresses

Primary practice location

9485 Mentor Ave
101
Mentor, OH 44060

Mailing address

PO Box 714328
Columbus, OH 43271-4328
Phone (800) 354-1985

Other identifiers 1

IdentifierTypeStateIssuer
2017258MedicaidOH

Other names 1

  • PrimeHealth Pediatrics Mentor Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OH

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20031217000963 OH Part B Supplier - Clinic/Group Practice 6002713922 Receives reassigned benefits from 333 practitioners
40 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment

Other NPIs on the same Medicare enrollment 39

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 39

National Provider Directory

National Provider Directory
Part of
Lake Medical Center

Locations

9485 Mentor Ave
Ste 101
Mentor, OH 44060
Phone (440) 205-5800

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150329600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1189036800000",
    "number": "1013951920",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 714328",
            "city": "COLUMBUS",
            "state": "OH",
            "postal_code": "432714328",
            "telephone_number": "800-354-1985",
            "fax_number": "440-350-4938"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9485 MENTOR AVE",
            "address_2": "101",
            "city": "MENTOR",
            "state": "OH",
            "postal_code": "44060",
            "telephone_number": "440-205-5800",
            "fax_number": "440-205-5801"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE HOSPITAL SYSTEM INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "LAKE HOSPITAL SYSTEM, INC.",
        "enumeration_date": "2006-06-15",
        "last_updated": "2007-09-06",
        "status": "A",
        "authorized_official_last_name": "TRACZ",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "440-354-1051",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2017258",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PrimeHealth Pediatrics Mentor",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mentor, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 6, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.