MEDICARE: INTERNAL MEDICINE OF LAKE CITY PA

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	261QP2300X	Primary Care Clinic/Center	BB6375477	FL

General Provider Information

NPI Number	:	1285822981
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERNAL MEDICINE OF LAKE CITY PA

Provider Business Mailing Address
First Line	:	289 SW STONEGATE TER
Second Line	:	SUITE 104
City	:	LAKE CITY
State	:	FL
Zip	:	32024-3456
Country	:	US
Telephone Number	:	386-755-1703
Fax Number	:	386-755-1744

Provider Business Practice Location Address
First Line	:	289 SW STONEGATE TER
Second Line	:	SUITE 104
City	:	LAKE CITY
State	:	FL
Zip	:	32024-3456
Country	:	US
Telephone Number	:	386-755-1703
Fax Number	:	386-755-1744

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SHAMMI K BALI
Credential	:	MD
Telephone Number	:	386-755-1703

Provider Enumeration Date	:	10/09/2007
Last Update Date	:	09/30/2013

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