Provider Demographics
NPI:1285822981
Name:INTERNAL MEDICINE OF LAKE CITY PA
Entity Type:Organization
Organization Name:INTERNAL MEDICINE OF LAKE CITY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAMMI
Authorized Official - Middle Name:K
Authorized Official - Last Name:BALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-755-1703
Mailing Address - Street 1:289 SW STONEGATE TER
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-3456
Mailing Address - Country:US
Mailing Address - Phone:386-755-1703
Mailing Address - Fax:386-755-1744
Practice Address - Street 1:289 SW STONEGATE TER
Practice Address - Street 2:SUITE 104
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32024-3456
Practice Address - Country:US
Practice Address - Phone:386-755-1703
Practice Address - Fax:386-755-1744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBB6375477261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8942Medicare PIN