Provider Demographics
NPI:1225556442
Name:LRI MEDICAL
Entity Type:Organization
Organization Name:LRI MEDICAL
Other - Org Name:LRI SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HONG
Authorized Official - Middle Name:
Authorized Official - Last Name:LOSSING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-746-0041
Mailing Address - Street 1:PO BOX 919357
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-9357
Mailing Address - Country:US
Mailing Address - Phone:352-746-1558
Mailing Address - Fax:352-746-3838
Practice Address - Street 1:5423 COMMERCIAL WAY
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606-1110
Practice Address - Country:US
Practice Address - Phone:352-228-4984
Practice Address - Fax:352-794-3843
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST FLORIDA MEDICAL ASSOCIATES P A
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280792100Medicaid