Provider Demographics
NPI:1851372494
Name:LAKE PULMONARY CRITICAL CARE P A
Entity Type:Organization
Organization Name:LAKE PULMONARY CRITICAL CARE P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BARBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-742-4631
Mailing Address - Street 1:1876 NIGHTINGALE LN
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4359
Mailing Address - Country:US
Mailing Address - Phone:352-742-4447
Mailing Address - Fax:352-742-4448
Practice Address - Street 1:1876 NIGHTINGALE LN
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4359
Practice Address - Country:US
Practice Address - Phone:352-742-4447
Practice Address - Fax:352-742-4448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RC0200X, 207RP1001X, 207RS0012X
FLARNP9218919363LA2200X, 364SC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254399100Medicaid
FL21518OtherBCBS PROVIDER NUMBER
FL2900100538OtherMEDICARE RAILROAD
FL21518OtherBCBS PROVIDER NUMBER
FL2900100538OtherMEDICARE RAILROAD