Provider Demographics
NPI:1366420606
Name:LAKELAND FOOT & ANKLE CENTER PA
Entity type:Organization
Organization Name:LAKELAND FOOT & ANKLE CENTER PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:G
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:863-682-3395
Mailing Address - Street 1:1543 LAKELAND HILLS BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3246
Mailing Address - Country:US
Mailing Address - Phone:863-682-3395
Mailing Address - Fax:863-802-1225
Practice Address - Street 1:1543 LAKELAND HILLS BLVD
Practice Address - Street 2:STE B
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3246
Practice Address - Country:US
Practice Address - Phone:863-682-3395
Practice Address - Fax:863-802-1225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO0002468213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL480024416OtherRAILROAD MEDICARE
FL65402OtherBLUE CROSS BLUE SHIELD
FL480024416OtherRAILROAD MEDICARE
FL65402AMedicare ID - Type Unspecified
FL1261910001Medicare NSC