Basic Information
Provider Information | |||||||||
NPI: | 1245226190 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LEESBURG REGIONAL MEDICAL CENTER INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 600 E. DIXIE AVENUE | ||||||||
Address2: | ATTN: REIMBURSEMENT DEPT. | ||||||||
City: | LEESBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 347485994 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3523235762 | ||||||||
FaxNumber: | 3523235039 | ||||||||
Practice Location | |||||||||
Address1: | 600 E DIXIE AVE | ||||||||
Address2: |   | ||||||||
City: | LEESBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 347485925 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3523235762 | ||||||||
FaxNumber: | 3523235239 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/26/2005 | ||||||||
LastUpdateDate: | 09/12/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARDEN | ||||||||
AuthorizedOfficialFirstName: | DIANE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 3523235002 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   | FL | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 328 | 01 | FL | BLUE CROSS ID | OTHER | 010107900 | 05 | FL |   | MEDICAID |