Provider Demographics
NPI:1225122070
Name:LAKELANDS ORTHOPAEDIC CLINIC PA
Entity Type:Organization
Organization Name:LAKELANDS ORTHOPAEDIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:POORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-323-0527
Mailing Address - Street 1:PO BOX 848287
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-8287
Mailing Address - Country:US
Mailing Address - Phone:864-229-2663
Mailing Address - Fax:864-223-5694
Practice Address - Street 1:102 GREGOR MENDEL CIR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-2315
Practice Address - Country:US
Practice Address - Phone:864-229-2663
Practice Address - Fax:864-223-5694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0378Medicaid
SCGP0378Medicaid
SC3975Medicare ID - Type UnspecifiedMEDICARE NUMBER
SC0423870001Medicare NSC