Provider Demographics
NPI:1336313550
Name:SOUTH LAKE CARDIOLOGY, LLC
Entity Type:Organization
Organization Name:SOUTH LAKE CARDIOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OSAMA
Authorized Official - Middle Name:F
Authorized Official - Last Name:AL-SULEIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-467-1234
Mailing Address - Street 1:3150 CITRUS TOWER BLVD
Mailing Address - Street 2:BUILDING 13, SUITE B
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6802
Mailing Address - Country:US
Mailing Address - Phone:407-467-1234
Mailing Address - Fax:
Practice Address - Street 1:3150 CITRUS TOWER BLVD
Practice Address - Street 2:BUILDING 13, SUITE B
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6802
Practice Address - Country:US
Practice Address - Phone:407-467-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86774207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H85184Medicare UPIN
FL57703ZMedicare PIN