Healthcare Provider Details

I. General information

NPI: 1114593555
Provider Name (Legal Business Name): LAKELAND REGIONAL HEALTH SYSTEMS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PARKVIEW PL FL 33805
LAKELAND FL
33805-4550
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD
LAKELAND FL
33805-4543
US

V. Phone/Fax

Practice location:
  • Phone: 863-687-1300
  • Fax: 863-687-1305
Mailing address:
  • Phone: 863-687-1100
  • Fax: 863-630-6528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

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