Provider Demographics
NPI:1003151903
Name:LPS MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:LPS MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CRUZ
Authorized Official - Middle Name:ADELMIS
Authorized Official - Last Name:SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-476-4011
Mailing Address - Street 1:1310 N MAIN ST STE 105
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-4244
Mailing Address - Country:US
Mailing Address - Phone:407-483-7975
Mailing Address - Fax:888-772-5242
Practice Address - Street 1:1310 N MAIN ST STE 105
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-4244
Practice Address - Country:US
Practice Address - Phone:407-483-7975
Practice Address - Fax:888-772-5242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-03
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME107498207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007-666-400Medicaid
FL004173700Medicaid
FLFP292YOtherMEDICARE PTAN
FLHI271AOtherMEDICARE GROUP PTAN