Healthcare Provider Details

I. General information

NPI: 1093653321
Provider Name (Legal Business Name): LAKELAND REGIONAL HEALTH SYSTEM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2026
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4406 S FLORIDA AVE STE 17
LAKELAND FL
33813-2182
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD ATTN: MANAGED CARE
LAKELAND FL
33805-4543
US

V. Phone/Fax

Practice location:
  • Phone: 863-646-5088
  • Fax: 863-904-4701
Mailing address:
  • Phone: 863-687-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LANCE GREEN
Title or Position: EVP/CFO
Credential:
Phone: 863-687-1100