Provider Demographics
NPI:1316180409
Name:GOOD SHEPHERD MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:GOOD SHEPHERD MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:B
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-686-5023
Mailing Address - Street 1:11373 CORTEZ BLVD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-5414
Mailing Address - Country:US
Mailing Address - Phone:352-596-4027
Mailing Address - Fax:352-597-9727
Practice Address - Street 1:11373 CORTEZ BLVD
Practice Address - Street 2:SUITE 209
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5414
Practice Address - Country:US
Practice Address - Phone:352-596-4027
Practice Address - Fax:352-597-9727
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOD SHEPHERD MEDICAL CLINIC PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0048810207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA62283Medicare UPIN
FL24312LMedicare PIN