NPIMap

Organization Active NPI

Lakeland Regional Health Systems, Inc.

Doing business as Lake Miriam Campus

  • Multi-Specialty Clinic/Center
  • Lakeland, FL
National Provider Identifier
1063858538
Registry record updated Jan 24, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X
Legal business name
LAKELAND REGIONAL HEALTH SYSTEMS, INC.
Doing business as
Lake Miriam Campus
Practice address
4710 S Florida Ave
Lakeland, FL 33813-2165
Phone
(863) 284-6800
Fax
(863) 284-6807
NPI assigned
May 10, 2013
Last updated
Jan 24, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 24, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Lance Green
Title
VP/Cfo
Phone
(863) 687-1100

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Multi-Specialty Clinic/Center 261QM1300X FL Primary
Family Nurse Practitioner 363LF0000X NU
Family Medicine Physician 207Q00000X NU
Internal Medicine Physician 207R00000X NU
Geriatric Medicine (Internal Medicine) Physician 207RG0300X NU
General Practice Physician 208D00000X NU

Addresses

Primary practice location

4710 S Florida Ave
Lakeland, FL 33813-2165

Mailing address

1324 Lakeland Hills Blvd
Managed Care Dept
Lakeland, FL 33805
Phone (863) 687-1100

Other identifiers 1

IdentifierTypeStateIssuer
263421005MedicaidFL

Other names 1

  • Lake Miriam Campus Doing business as

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D0947587Lakeland Regional Health4710 South Florida Ave, Lakeland, FL 33813Certificate of waiverApr 15, 2027

National Provider Directory

National Provider Directory
Tax ID family
Lakeland Regional HLTH Syst36 organizations share this tax ID, including this one

Other organizations with this tax ID 35

Organizations that report the same tax identification number in the National Provider Directory.

View all 35

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1368144000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1674518400000",
    "number": "1063858538",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1324 LAKELAND HILLS BLVD",
            "address_2": "MANAGED CARE DEPT",
            "city": "LAKELAND",
            "state": "FL",
            "postal_code": "33805",
            "telephone_number": "863-687-1100",
            "fax_number": "863-630-6528"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4710 S FLORIDA AVE",
            "city": "LAKELAND",
            "state": "FL",
            "postal_code": "338132165",
            "telephone_number": "863-284-6800",
            "fax_number": "863-284-6807"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKELAND REGIONAL HEALTH SYSTEMS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-05-10",
        "last_updated": "2023-01-24",
        "certification_date": "2023-01-24",
        "status": "A",
        "authorized_official_last_name": "GREEN",
        "authorized_official_first_name": "LANCE",
        "authorized_official_title_or_position": "VP/CFO",
        "authorized_official_telephone_number": "863-687-1100"
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": "FL",
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207RG0300X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Geriatric Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "263421005",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lake Miriam Campus",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lakeland, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 24, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.