Provider Demographics
NPI:1508999673
Name:PULMONARY CRITICAL CARE & SLEEP SPECIALISTS OF LAKE COUNTY, PA
Entity Type:Organization
Organization Name:PULMONARY CRITICAL CARE & SLEEP SPECIALISTS OF LAKE COUNTY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:JALLOUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-508-1727
Mailing Address - Street 1:PO BOX 386
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-0386
Mailing Address - Country:US
Mailing Address - Phone:352-508-1727
Mailing Address - Fax:877-762-7377
Practice Address - Street 1:2762 DORA AVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4970
Practice Address - Country:US
Practice Address - Phone:352-508-1727
Practice Address - Fax:877-762-7377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97922207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH36556Medicare UPIN
FLAC198Medicare PIN