NPIMap

Organization Active NPI

Lake Hospital System Inc.

  • Urgent Care Clinic/Center
  • Willowick, OH
National Provider Identifier
1912967209
Registry record updated Feb 15, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Urgent Care Clinic/CenterTaxonomy code 261QU0200X
Legal business name
LAKE HOSPITAL SYSTEM INC.
Practice address
29804 Lake Shore Blvd
Willowick, OH 44095-4611
Phone
(440) 585-3322
Fax
(440) 585-1962
NPI assigned
Mar 23, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 15, 2017

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

Authorized official

Name
Mr. Bob Tracz
Title
Cfo
Phone
(440) 354-1953

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X
General Practice PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208D00000X
Urgent Care Clinic/Center 261QU0200X Primary

Addresses

Primary practice location

29804 Lake Shore Blvd
Willowick, OH 44095-4611

Mailing address

PO Box 781348
Detroit, MI 48278-1348
Phone (800) 354-1895

Other identifiers 6

IdentifierTypeStateIssuer
264200001OtherOHDEPT OF LABOR
80507OtherOHQUALCHOICE
2017301MedicaidOH
264200001OtherOHFEDERAL BLACK LUNG
6600162OtherOHUNITED HEALTHCARE
2440148MedicaidOH

Other names 1

  • Lake Health Urgent Care and Walk In Center Other name

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
Tax ID family
Lake Medical Center37 organizations share this tax ID, including this one

Other organizations with this tax ID 36

Organizations that report the same tax identification number in the National Provider Directory.

View all 36

Practitioners & affiliated clinicians

Practitioners 17

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

View all 17

NPI Registry JSON

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

{
    "created_epoch": "1143072000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1487116800000",
    "number": "1912967209",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 781348",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482781348",
            "telephone_number": "800-354-1895",
            "fax_number": "440-585-1962"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "29804 LAKE SHORE BLVD",
            "city": "WILLOWICK",
            "state": "OH",
            "postal_code": "440954611",
            "telephone_number": "440-585-3322",
            "fax_number": "440-585-1962"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE HOSPITAL SYSTEM INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-23",
        "last_updated": "2017-02-15",
        "status": "A",
        "authorized_official_last_name": "TRACZ",
        "authorized_official_first_name": "BOB",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "440-354-1953",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "General Practice",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QU0200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Urgent Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DEPT OF LABOR",
            "identifier": "264200001",
            "state": "OH"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "QUALCHOICE",
            "identifier": "80507",
            "state": "OH"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2017301",
            "state": "OH"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FEDERAL BLACK LUNG",
            "identifier": "264200001",
            "state": "OH"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED HEALTHCARE",
            "identifier": "6600162",
            "state": "OH"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2440148",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lake Health Urgent Care and Walk In Center",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Willowick, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 15, 2017; 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.