Provider Demographics
NPI:1316931512
Name:LAKE-SUMTER EMERGENCY MEDICAL SERVICES
Entity type:Organization
Organization Name:LAKE-SUMTER EMERGENCY MEDICAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PFS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:PORTER
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-385-2530
Mailing Address - Street 1:2761 W OLD US HWY 441
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-3500
Mailing Address - Country:US
Mailing Address - Phone:352-383-4554
Mailing Address - Fax:352-385-9063
Practice Address - Street 1:2761 W OLD US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-3500
Practice Address - Country:US
Practice Address - Phone:352-383-4554
Practice Address - Fax:352-385-9063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-02
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25133416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL400077300Medicaid
FLA0725Medicare ID - Type UnspecifiedMEDICARE PROVIDER #