1467647685 NPI number — SOUTH LAKE GASTROENTEROLOGY INC

Table of content: (NPI 1467647685)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467647685 NPI number — SOUTH LAKE GASTROENTEROLOGY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH LAKE GASTROENTEROLOGY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467647685
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 120930
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLERMONT
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34712-0930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-242-1665
Provider Business Mailing Address Fax Number:
352-243-1649

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2040 OAKLEY SEAVER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLERMONT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34711-1962
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-242-1665
Provider Business Practice Location Address Fax Number:
352-243-1649
Provider Enumeration Date:
09/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RAMPERSAD
Authorized Official First Name:
RAMESH
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
352-242-1665

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME74082 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5858631 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: E0302Z . This is a "MEDICARE INDIVIDUAL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 256031300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 43437 . This is a "FL BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 023935500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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