Basic Information
| Provider Information | |||||||||
| NPI: | 1093975062 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKEWOOD RANCH MEDICAL GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 281741 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303841741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417822800 | ||||||||
| FaxNumber: | 9417822513 | ||||||||
| Practice Location | |||||||||
| Address1: | 8340 LAKEWOOD RANCH BLVD | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | LAKEWOOD RANCH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342025180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417822800 | ||||||||
| FaxNumber: | 9417822513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2008 | ||||||||
| LastUpdateDate: | 05/24/2010 | ||||||||
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| AuthorizedOfficialLastName: | CARAG | ||||||||
| AuthorizedOfficialFirstName: | CECILIA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DELEGATED OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9417822800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | DN8672 | 01 | FL | RAIL ROAD MEDICARE | OTHER |