MEDICARE: SRINIVAS SAMAK MD.PA

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	207R00000X	Internal Medicine Physician	28681	FL

General Provider Information

NPI Number	:	1265613509
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SRINIVAS SAMAK MD.PA

Provider Business Mailing Address
First Line	:	1500 LAKELAND HILLS BLVD
Second Line	:	#4
City	:	LAKELAND
State	:	FL
Zip	:	33805-3257
Country	:	US
Telephone Number	:	863-688-3674
Fax Number	:	863-616-9902

Provider Business Practice Location Address
First Line	:	1500 LAKELAND HILLS BLVD
Second Line	:	#4
City	:	LAKELAND
State	:	FL
Zip	:	33805-3257
Country	:	US
Telephone Number	:	863-688-3674
Fax Number	:	863-616-9902

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SRINIVAS P SAMAK
Credential	:	MD
Telephone Number	:	863-688-3674

Provider Enumeration Date	:	11/15/2007
Last Update Date	:	11/15/2007

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