MEDICARE: SOUTH LAKE PRIMARY CARE P A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ME0071348	FL

General Provider Information

NPI Number	:	1164783528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH LAKE PRIMARY CARE P A

Provider Business Mailing Address
First Line	:	1503 SUNRISE PLAZA DR
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34714-6200
Country	:	US
Telephone Number	:	352-243-3800
Fax Number	:	352-243-3804

Provider Business Practice Location Address
First Line	:	219 W MYERS BLVD
Second Line	:	SUITE C
City	:	MASCOTTE
State	:	FL
Zip	:	34753-9793
Country	:	US
Telephone Number	:	352-557-4840
Fax Number	:	352-557-4839

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	RAMON SUEIRO
Credential	:	MD
Telephone Number	:	352-557-4840

Provider Enumeration Date	:	06/01/2012
Last Update Date	:	08/30/2013

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