Provider Demographics
NPI:1275610362
Name:COUNTRYSIDE MEDICAL PA
Entity Type:Organization
Organization Name:COUNTRYSIDE MEDICAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:BARUCH
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:352-873-4458
Mailing Address - Street 1:PO BOX 770719
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34477-0719
Mailing Address - Country:US
Mailing Address - Phone:352-873-4458
Mailing Address - Fax:352-873-8116
Practice Address - Street 1:7860 SW 103RD STREET RD
Practice Address - Street 2:BLDG 100 SUITE 101
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34476-8623
Practice Address - Country:US
Practice Address - Phone:352-873-4458
Practice Address - Fax:352-873-8116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CG9421OtherRR MEDICARE
FL38908Medicare PIN