Provider Demographics
NPI:1972048536
Name:TLC MEDICAL GROUP,INC.
Entity Type:Organization
Organization Name:TLC MEDICAL GROUP,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:B
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-528-9074
Mailing Address - Street 1:1391 NW SAINT LUCIE WEST BLVD
Mailing Address - Street 2:#216
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2196
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:537 NW LAKE WHITNEY PL
Practice Address - Street 2:UNIT 103-106
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1620
Practice Address - Country:US
Practice Address - Phone:772-877-8578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-05
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIW922AMedicare PIN