NPIMap

Organization Active NPI

Lake Hospital System, Inc.

  • Vascular Surgery Physician
  • Willoughby, OH
National Provider Identifier
1124255278
Registry record updated Apr 25, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Vascular Surgery PhysicianTaxonomy code 2086S0129X
Legal business name
LAKE HOSPITAL SYSTEM, INC.
Practice address
36001 Euclid Ave
B-3
Willoughby, OH 44094-4643
Phone
(440) 953-1898
Fax
(440) 953-9296
NPI assigned
Jun 16, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 25, 2011

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

Authorized official

Name
Richard D Cicero
Title
Sr. VP, Business Development
Phone
(440) 354-1739

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208600000X
Vascular Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2086S0129X Primary

Addresses

Primary practice location

36001 Euclid Ave
B-3
Willoughby, OH 44094-4643

Mailing address

PO Box 714328
Columbus, OH 43271-4328
Phone (440) 354-1899

Other names 1

  • Lake Health Physician Group Vascular Access Surgery 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

Locations

36001 Euclid Ave
#B3
Willoughby, OH 44094
Phone (440) 953-1898

NPI Registry JSON

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

{
    "created_epoch": "1245110400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1303689600000",
    "number": "1124255278",
    "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": "440-354-1899",
            "fax_number": "440-354-1089"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "36001 EUCLID AVE",
            "address_2": "B-3",
            "city": "WILLOUGHBY",
            "state": "OH",
            "postal_code": "440944643",
            "telephone_number": "440-953-1898",
            "fax_number": "440-953-9296"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE HOSPITAL SYSTEM, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-06-16",
        "last_updated": "2011-04-25",
        "status": "A",
        "authorized_official_last_name": "CICERO",
        "authorized_official_first_name": "RICHARD",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "SR. VP, BUSINESS DEVELOPMENT",
        "authorized_official_telephone_number": "440-354-1739"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2086S0129X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Surgery, Vascular Surgery",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lake Health Physician Group Vascular Access Surgery",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Willoughby, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 25, 2011; 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.