Provider Demographics
NPI:1285611210
Name:INTERNAL MEDICINE ASSOCIATES OF LAKE COUNTY, P.A.
Entity type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATES OF LAKE COUNTY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-314-2424
Mailing Address - Street 1:619 W DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-2602
Mailing Address - Country:US
Mailing Address - Phone:352-314-2424
Mailing Address - Fax:352-314-3010
Practice Address - Street 1:619 W DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-2602
Practice Address - Country:US
Practice Address - Phone:352-314-2424
Practice Address - Fax:352-314-3010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-30
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45358OtherBCBS OF FLORIDA
FL259964300Medicaid
FL45358OtherBCBS OF FLORIDA