Provider Demographics
NPI:1215609011
Name:LAKELAND REGIONAL HEALTH SYSTEM, INC
Entity type:Organization
Organization Name:LAKELAND REGIONAL HEALTH SYSTEM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:EVP/CFO
Authorized Official - Phone:863-687-1100
Mailing Address - Street 1:ATTN MANAGED CARE DEPARTMENT
Mailing Address - Street 2:1324 LAKELAND HILLS BLVD
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805
Mailing Address - Country:US
Mailing Address - Phone:863-687-1100
Mailing Address - Fax:863-284-6825
Practice Address - Street 1:455 EMERALD AVE
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4716
Practice Address - Country:US
Practice Address - Phone:863-676-0014
Practice Address - Fax:863-284-6825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-30
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263421021Medicaid