MEDICARE: LAKESIDE OCCUPATIONAL MEDICAL CENTERS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QX0100X	Occupational Medicine Clinic/Center		FL
2	261QX0100X	Occupational Medicine Clinic/Center

General Provider Information

NPI Number	:	1194763557
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE OCCUPATIONAL MEDICAL CENTERS, INC.

Provider Business Mailing Address
First Line	:	5406 HOOVER BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33634-5330
Country	:	US
Telephone Number	:	813-248-8149
Fax Number	:	813-884-7085

Provider Business Practice Location Address
First Line	:	5406 HOOVER BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33634-5330
Country	:	US
Telephone Number	:	813-248-8149
Fax Number	:	813-884-7085

Authorized Official
Title or Position	:	VP OF OPERATIONS
Name	:	MRS. SANDRA L. DRIVER
Credential	:	RN
Telephone Number	:	727-532-7647

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	12/07/2009

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