Basic Information
| Provider Information | |||||||||
| NPI: | 1063858538 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKELAND REGIONAL HEALTH SYSTEMS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKE MIRIAM CAMPUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1324 LAKELAND HILLS BLVD | ||||||||
| Address2: | MANAGED CARE DEPT | ||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636871100 | ||||||||
| FaxNumber: | 8636306528 | ||||||||
| Practice Location | |||||||||
| Address1: | 4710 S FLORIDA AVE | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338132165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632846800 | ||||||||
| FaxNumber: | 8632846807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2013 | ||||||||
| LastUpdateDate: | 07/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | LANCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 8636871100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.