1962552232 NPI number — LAKELAND SURGICAL & DIAGNOSTIC CENTER LLP

Table of content: (NPI 1962552232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962552232 NPI number — LAKELAND SURGICAL & DIAGNOSTIC CENTER LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKELAND SURGICAL & DIAGNOSTIC CENTER LLP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962552232
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 S MISSOURI AVE
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33815-4600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-683-2428
Provider Business Mailing Address Fax Number:
863-686-9873

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
818 GRIFFIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33805-2440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-687-0566
Provider Business Practice Location Address Fax Number:
863-616-9289
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DUNCAN
Authorized Official First Name:
EMILY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
863-683-2428

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  1213 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 014447700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6H3 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 10111447AC17 . This is a "BEECHSTREET CDPHP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 490003123 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 014447700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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