Basic Information
| Provider Information | |||||||||
| NPI: | 1245499300 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOOD SHEPHERD MEDICAL CLINIC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8425 NORTHCLIFFE BLVD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346061107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526886346 | ||||||||
| FaxNumber: | 3526889103 | ||||||||
| Practice Location | |||||||||
| Address1: | 8425 NORTHCLIFFE BLVD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346061107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526886346 | ||||||||
| FaxNumber: | 3526889103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2008 | ||||||||
| LastUpdateDate: | 08/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3526661011 | ||||||||
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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 | 207R00000X | ME76767 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | CE7176 | 01 | FL | MEDICARE RAILROAD | OTHER |