Provider Demographics
NPI:1962552752
Name:PSYCHIATRIC ASSOCIATES OF LAKE CITY PA
Entity type:Organization
Organization Name:PSYCHIATRIC ASSOCIATES OF LAKE CITY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHILPA
Authorized Official - Middle Name:U
Authorized Official - Last Name:MHATRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-755-1800
Mailing Address - Street 1:165 SW VISION GLENN
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-1111
Mailing Address - Country:US
Mailing Address - Phone:386-755-1800
Mailing Address - Fax:386-758-8770
Practice Address - Street 1:165 SW VISION GLENN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-1111
Practice Address - Country:US
Practice Address - Phone:386-755-1800
Practice Address - Fax:386-758-8770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00275612084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264574342OtherCHAMPUS TRICARE
FLME 0027561OtherFLORIDA LICENSE
FL01251OtherBC BS OF FL
FL037553500Medicaid
FL083097OtherMHN
FL406263894OtherRAIL ROAD MEDICARE
FLME 0027561OtherFLORIDA LICENSE
FLD 50048Medicare UPIN
FL264574342OtherCHAMPUS TRICARE