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General NPI Number Information
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NPI Number | 1285822981
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Entity Type | Organization
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Legal Business Name | INTERNAL MEDICINE OF LAKE CITY PA
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Dates
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Enumeration Date | 10/09/2007
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Last Update Date | 09/30/2013
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Provider Practice Location Address
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Address Line | 289 SW STONEGATE TER SUITE 104
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City | LAKE CITY
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State | FL
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Zip | 32024-3456
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Country | US
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Telephone | 386-755-1703
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Fax | 386-755-1744
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Provider Business Mailing Address
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Address Line | 289 SW STONEGATE TER SUITE 104
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City | LAKE CITY
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State | FL
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Zip | 32024-3456
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Country | US
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Telephone | 386-755-1703
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Fax | 386-755-1744
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SHAMMI K BALI
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Credential | MD
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Telephone | 386-755-1703
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | BB6375477
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License Number State | FL
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