Provider Demographics
NPI:1881853943
Name:GOOD SHEPHERD MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:GOOD SHEPHERD MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:B
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-666-1011
Mailing Address - Street 1:8425 NORTHCLIFFE BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-1107
Mailing Address - Country:US
Mailing Address - Phone:352-688-6346
Mailing Address - Fax:352-688-9103
Practice Address - Street 1:8425 NORTHCLIFFE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606-1107
Practice Address - Country:US
Practice Address - Phone:352-688-6346
Practice Address - Fax:352-688-9103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73749207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCE7176OtherMEDICARE RAILROAD
FL24312DMedicare PIN
FLG63782Medicare UPIN