Basic Information
| Provider Information | |||||||||
| NPI: | 1336301829 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOOD SHEPHERD MEDICAL CLINIC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8425 NORTHCLIFFE BLVD | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346061107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526865255 | ||||||||
| FaxNumber: | 3526661142 | ||||||||
| Practice Location | |||||||||
| Address1: | 8425 NORTHCLIFFE BLVD | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346061107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526865255 | ||||||||
| FaxNumber: | 3526661142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2008 | ||||||||
| LastUpdateDate: | 07/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3526832495 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GOOD SHEPHERD MEDICAL CLINIC PA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME0071038 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.