Provider Demographics
NPI:1194115204
Name:LEE COUNTY MEDICAL GROUP CORP
Entity type:Organization
Organization Name:LEE COUNTY MEDICAL GROUP CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:SALOME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-747-1000
Mailing Address - Street 1:742 FULLER AVE S
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33974-7576
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:742 FULLER AVE S
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33974-7576
Practice Address - Country:US
Practice Address - Phone:239-274-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty