Provider Demographics
NPI:1871663153
Name:LEESBURG REGIONAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:LEESBURG REGIONAL MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-323-5002
Mailing Address - Street 1:600 E DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5925
Mailing Address - Country:US
Mailing Address - Phone:352-323-5762
Mailing Address - Fax:352-323-5239
Practice Address - Street 1:600 E DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5925
Practice Address - Country:US
Practice Address - Phone:352-323-5762
Practice Address - Fax:352-323-5239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010107900Medicaid
FL328OtherBLUE CROSS BLUE SHIELD ID
FL010107900Medicaid
FL328OtherBLUE CROSS BLUE SHIELD ID