Provider Demographics
NPI:1467647685
Name:SOUTH LAKE GASTROENTEROLOGY INC
Entity Type:Organization
Organization Name:SOUTH LAKE GASTROENTEROLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAMESH
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMPERSAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-242-1665
Mailing Address - Street 1:PO BOX 120930
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34712-0930
Mailing Address - Country:US
Mailing Address - Phone:352-242-1665
Mailing Address - Fax:352-243-1649
Practice Address - Street 1:2040 OAKLEY SEAVER DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1962
Practice Address - Country:US
Practice Address - Phone:352-242-1665
Practice Address - Fax:352-243-1649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74082174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5858631OtherAETNA
FLE0302ZOtherMEDICARE INDIVIDUAL
FL256031300Medicaid
FL43437OtherFL BCBS
FL43437OtherFL BCBS
FLK9666Medicare PIN