Healthcare Provider Details

I. General information

NPI: 1104063114
Provider Name (Legal Business Name): LEESBURG REGIONAL MEDICAL CENTER PHYSICIAN SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2009
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E DIXIE AVE
LEESBURG FL
34748-5925
US

IV. Provider business mailing address

600 E DIXIE AVE
LEESBURG FL
34748-5925
US

V. Phone/Fax

Practice location:
  • Phone: 523-594-0827
  • Fax: 352-323-5039
Mailing address:
  • Phone: 352-323-5002
  • Fax: 352-323-5039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME102387
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME101492
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME062340
License Number StateFL

VIII. Authorized Official

Name: MRS. HEATHER LONG
Title or Position: PRESIDENT, CEO
Credential:
Phone: 352-323-5761