Provider Demographics
NPI:1801838313
Name:SOUTH LAKE INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:SOUTH LAKE INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-394-1969
Mailing Address - Street 1:1101 CITRUS TOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1905
Mailing Address - Country:US
Mailing Address - Phone:352-243-2141
Mailing Address - Fax:352-243-1309
Practice Address - Street 1:1371 CITRUS TOWER BLVD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1924
Practice Address - Country:US
Practice Address - Phone:352-243-2141
Practice Address - Fax:352-243-1309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK-5621Medicare PIN