Basic Information
| Provider Information | |||||||||
| NPI: | 1992216568 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELITE MEDICAL SERVICES AT LAKESIDE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12010 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321202010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862747800 | ||||||||
| FaxNumber: | 3862747801 | ||||||||
| Practice Location | |||||||||
| Address1: | LAKESIDE MEDICAL CENTER EMERGENCY DEPARTMENT | ||||||||
| Address2: | 39200 HOOKER HWY | ||||||||
| City: | BELLE GLADE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334305368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619966571 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2017 | ||||||||
| LastUpdateDate: | 12/12/2017 | ||||||||
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| AuthorizedOfficialLastName: | SCHEPPKE | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5614362291 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.