Provider Demographics
NPI: | 1669817144 |
---|---|
Name: | LAKELAND REGIONAL HEALTH SYSTEMS, INC. |
Entity Type: | Organization |
Organization Name: | LAKELAND REGIONAL HEALTH SYSTEMS, INC. |
Other - Org Name: | GRASSLANDS CAMPUS |
Other - Org Type: | Other Name |
Authorized Official - Title/Position: | VP CFO |
Authorized Official - Prefix: | |
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: | MANAGED CARE DEPT |
Mailing Address - City: | LAKELAND |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33805 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 863-687-1100 |
Mailing Address - Fax: | 863-630-6528 |
Practice Address - Street 1: | 3030 HARDEN BLVD |
Practice Address - Street 2: | |
Practice Address - City: | LAKELAND |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33803-7952 |
Practice Address - Country: | US |
Practice Address - Phone: | 863-284-5115 |
Practice Address - Fax: | 863-413-4739 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2013-05-09 |
Last Update Date: | 2023-01-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
207Q00000X, 207R00000X, 207RC0200X, 207RE0101X, 207RP1001X, 207RR0500X, 207V00000X, 207XX0005X, 207Y00000X, 207YX0905X, 208000000X, 2084N0400X, 2086S0105X, 208D00000X | ||
FL | 261QM1300X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RC0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | Group - Multi-Specialty |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207XX0005X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | Group - Multi-Specialty |
No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
No | 207YX0905X | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery | Group - Multi-Specialty |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 2086S0105X | Allopathic & Osteopathic Physicians | Surgery | Surgery of the Hand | Group - Multi-Specialty |
No | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 263421007 | Medicaid |