Healthcare Provider Details

I. General information

NPI: 1487068672
Provider Name (Legal Business Name): LAKELAND REGIONAL HEALTH SYSTEM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2014
Last Update Date: 01/04/2023
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 LAKELAND HILLS BLVD PAVILLION - OBGYN
LAKELAND FL
33805-4543
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD
LAKELAND FL
33805-4543
US

V. Phone/Fax

Practice location:
  • Phone: 863-284-6860
  • Fax: 863-688-7959
Mailing address:
  • Phone: 863-687-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

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