MEDICARE: LAKELAND FL ENDOSCOPY ASC LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center	1230	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00221727	OTHER	FL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649244567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKELAND FL ENDOSCOPY ASC LLC

Provider Business Mailing Address
First Line	:	3340 LAKELAND HILLS BLVD
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33805-1974
Country	:	US
Telephone Number	:	863-682-3239
Fax Number	:	863-682-3462

Provider Business Practice Location Address
First Line	:	3340 LAKELAND HILLS BLVD
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33805-1974
Country	:	US
Telephone Number	:	863-682-3239
Fax Number	:	863-682-3462

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. PHILLIP A CLENDENIN
Credential	:
Telephone Number	:	615-665-1283

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	09/07/2023

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