=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245389311
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE PARK MEDICAL CARE CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2007
-----------------------------------------------------
Last Update Date | 05/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 415 US HIGHWAY 1 SUITE D
-----------------------------------------------------
City | LAKE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33403-3585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-842-5900
-----------------------------------------------------
Fax | 561-844-6037
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 US HIGHWAY 1 SUITE D
-----------------------------------------------------
City | LAKE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33403-3585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-842-5900
-----------------------------------------------------
Fax | 561-844-6037
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER BILLING COMPANY
-----------------------------------------------------
Name | KAREN BARLOW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-748-2889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME0048980
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------