Provider Demographics
NPI:1326207481
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 1:8425 NORTHCLIFFE BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-1107
Mailing Address - Country:US
Mailing Address - Phone:352-683-2495
Mailing Address - Fax:352-683-5308
Practice Address - Street 1:8425 NORTHCLIFFE BLVD STE 107
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606-1107
Practice Address - Country:US
Practice Address - Phone:352-683-2495
Practice Address - Fax:352-683-5308
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOD SHEPHERD MEDICAL CLINIC PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-04
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME43991207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL24312JMedicare PIN
FLD62022Medicare UPIN