MEDICARE: PRIMARY MEDICAL CENTER OF LAKELAND, 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	173000000X	Legal Medicine	ME27448	FL

Other Identifiers

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

General Provider Information

NPI Number	:	1780621607
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY MEDICAL CENTER OF LAKELAND, LLC

Provider Business Mailing Address
First Line	:	1417 LAKELAND HILLS BLVD
Second Line	:	SUITE #106
City	:	LAKELAND
State	:	FL
Zip	:	33805-3200
Country	:	US
Telephone Number	:	863-687-4575
Fax Number	:	863-616-1342

Provider Business Practice Location Address
First Line	:	1417 LAKELAND HILLS BLVD
Second Line	:	SUITE #106
City	:	LAKELAND
State	:	FL
Zip	:	33805-3200
Country	:	US
Telephone Number	:	863-687-4575
Fax Number	:	863-616-1342

Authorized Official
Title or Position	:	MANAGER MEMBER
Name	:	MARC A GUERRIER JR.
Credential	:	MD
Telephone Number	:	863-687-4575

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	11/08/2016

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