Basic Information
| Provider Information | |||||||||
| NPI: | 1871663153 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEESBURG REGIONAL MEDICAL CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 E DIXIE AVE | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347485925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523235762 | ||||||||
| FaxNumber: | 3523235239 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 E DIXIE AVE | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347485925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523235762 | ||||||||
| FaxNumber: | 3523235239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 12/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | HARDEN | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3523235002 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 010107900 | 05 | FL | MEDICAID | 328 | 01 | FL | BLUE CROSS BLUE SHIELD ID | OTHER |