Provider Demographics
NPI:1962552232
Name:LAKELAND SURGICAL & DIAGNOSTIC CENTER LLP
Entity type:Organization
Organization Name:LAKELAND SURGICAL & DIAGNOSTIC CENTER LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-683-2428
Mailing Address - Street 1:115 S MISSOURI AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33815-4600
Mailing Address - Country:US
Mailing Address - Phone:863-683-2428
Mailing Address - Fax:863-686-9873
Practice Address - Street 1:818 GRIFFIN RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-2440
Practice Address - Country:US
Practice Address - Phone:863-687-0566
Practice Address - Fax:863-616-9289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1213261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014447700Medicaid
FL6H3OtherBCBS
FL10111447AC17OtherBEECHSTREET CDPHP
FL490003123OtherRR MEDICARE
FL490003123OtherRR MEDICARE