Provider Demographics
NPI:1114393469
Name:LAKELAND REGIONAL HEALTH SYSTEM, INC
Entity Type:Organization
Organization Name:LAKELAND REGIONAL HEALTH SYSTEM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-687-1100
Mailing Address - Street 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:MANAGED CARE DEPT
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805
Mailing Address - Country:US
Mailing Address - Phone:863-687-1100
Mailing Address - Fax:863-630-6528
Practice Address - Street 1:3644 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812-4105
Practice Address - Country:US
Practice Address - Phone:863-284-1583
Practice Address - Fax:863-413-4822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-20
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive SurgeryGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263421022Medicaid