Healthcare Provider Details

I. General information

NPI: 1114393469
Provider Name (Legal Business Name): LAKELAND REGIONAL HEALTH SYSTEM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2015
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3644 INNOVATION DR
LAKELAND FL
33812-4105
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD MANAGED CARE DEPT
LAKELAND FL
33805
US

V. Phone/Fax

Practice location:
  • Phone: 863-284-1583
  • Fax: 863-413-4822
Mailing address:
  • Phone: 863-687-1100
  • Fax: 863-630-6528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
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: CFO
Credential:
Phone: 863-687-1100