Provider Demographics
NPI:1508258906
Name:LAKELAND REGIONAL HEALTH SYSTEMS, INC.
Entity Type:Organization
Organization Name:LAKELAND REGIONAL HEALTH SYSTEMS, INC.
Other - Org Name:LAKELAND HIGHLANDS CAMPUS
Other - Org Type:Other Name
Authorized Official - Title/Position:VP CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-687-1100
Mailing Address - Street 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4543
Mailing Address - Country:US
Mailing Address - Phone:863-687-1100
Mailing Address - Fax:863-687-1473
Practice Address - Street 1:3015 LAKELAND HIGHLANDS RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4339
Practice Address - Country:US
Practice Address - Phone:863-682-7737
Practice Address - Fax:863-682-0761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-23
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207LP2900X, 207Q00000X, 207V00000X, 208D00000X
FL261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263421013Medicaid