NPIMap

Organization Active NPI

Lake Hospital System, Inc.

Doing business as PrimeHealth Internal Medicine Mentor

  • Internal Medicine Physician
  • Mentor, OH
National Provider Identifier
1861420804
Registry record updated Sep 6, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
LAKE HOSPITAL SYSTEM, INC.
Doing business as
PrimeHealth Internal Medicine Mentor
Practice address
9485 Mentor Ave
#210
Mentor, OH 44060-4597
Phone
(440) 205-5745
Fax
(440) 205-5735
NPI assigned
Jun 29, 2006
Last updated
Sep 6, 2007By the provider in NPPES
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
Internal Medicine Physician 207R00000X NU Primary

Addresses

Primary practice location

9485 Mentor Ave
#210
Mentor, OH 44060-4597

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
2183499MedicaidOH

Other names 1

  • PrimeHealth Internal Medicine 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

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1151539200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1189036800000",
    "number": "1861420804",
    "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": "#210",
            "city": "MENTOR",
            "state": "OH",
            "postal_code": "440604597",
            "telephone_number": "440-205-5745",
            "fax_number": "440-205-5735"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE HOSPITAL SYSTEM, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "LAKE HOSPITAL SYSTEM, INC.",
        "enumeration_date": "2006-06-29",
        "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": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2183499",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PrimeHealth Internal Medicine 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.