NPIMap

Organization Active NPI

Lake Mary Surgery Center LLC

  • Ambulatory Surgical Clinic/Center
  • Lake Mary, FL
National Provider Identifier
1174530752
Registry record updated Feb 21, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X
License
1204 Issued in FL
Legal business name
LAKE MARY SURGERY CENTER LLC
Practice address
460 Saint Charles CT
Lake Mary, FL 32746-2103
Phone
(407) 585-0260
Fax
(407) 585-0264
NPI assigned
Aug 3, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 21, 2023

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

Authorized official

Name
Jennifer Boyd Baldock
Title
Officer and Authorized Official
Phone
(615) 234-5954

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Ambulatory Surgical Clinic/Center 261QA1903X 1204 FL Primary

Addresses

Primary practice location

460 Saint Charles CT
Lake Mary, FL 32746-2103

Mailing address

460 Saint Charles CT
Lake Mary, FL 32746-2103
Phone (407) 585-0260

Other identifiers 1

IdentifierTypeStateIssuer
075897300MedicaidFL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20041022000728 FL Part B Supplier - Ambulatory Surgical Center 8628039617 Practice locations: Lake Mary, FL

Care Compare: Ambulatory surgical center

Medicare Care Compare
Listed as
Lake Mary Surgery Center LLCCCN 10C0001429
Medicare certification status
ActiveFrom the Provider of Services file

National Provider Directory

National Provider Directory

Networks

  • Optimum HealthCare HMO NetworkPlans: Optimum Diamond Rewards (HMO C-SNP) (H5594-028-000, H5594); Optimum Diamond (HMO C-SNP) (H5594-036-000, H5594); Optimum Diamond Rewards (HMO C-SNP) (H5594-034-000, H5594); Optimum Diamond Rewards COPD (HMO C-SNP) (H5594-029-000, H5594); Optimum Platinum Plan (HMO) (H5594-002-000, H5594); Optimum Gold Plus Plan (HMO) (H5594-032-000, H5594); Optimum Diamond Savings COPD (HMO C-SNP) (H5594-031-000, H5594); Optimum Diamond Savings (HMO C-SNP) (H5594-030-000, H5594); Optimum Diamond Rewards COPD (HMO C-SNP) (H5594-035-000, H5594)
  • Freedom Health HMO NetworkPlans: Freedom Platinum Rewards Plan Rx (HMO) (H5427-102-000, H5427); Freedom VIP Care (HMO C-SNP) (H5427-070-000, H5427); Freedom VIP Rewards (HMO C-SNP) (H5427-108-000, H5427); Freedom VIP Rewards (HMO C-SNP) (H5427-099-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-107-000, H5427); Freedom Maximo (HMO-POS) (H5427-113-000, H5427); Freedom Savings Plan (HMO) (H5427-052-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-096-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-105-000, H5427); Freedom Medi-Medi Full (HMO D-SNP) (H5427-087-000, H5427)…

Practitioners & affiliated clinicians

Practitioners 26

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 26

NPI Registry JSON

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

{
    "created_epoch": "1154563200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1676937600000",
    "number": "1174530752",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "460 SAINT CHARLES CT",
            "city": "LAKE MARY",
            "state": "FL",
            "postal_code": "327462103",
            "telephone_number": "407-585-0260",
            "fax_number": "407-585-0264"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "460 SAINT CHARLES CT",
            "city": "LAKE MARY",
            "state": "FL",
            "postal_code": "327462103",
            "telephone_number": "407-585-0260",
            "fax_number": "407-585-0264"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE MARY SURGERY CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-03",
        "last_updated": "2023-02-21",
        "certification_date": "2023-02-21",
        "status": "A",
        "authorized_official_last_name": "BALDOCK",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "BOYD",
        "authorized_official_title_or_position": "OFFICER AND AUTHORIZED OFFICIAL",
        "authorized_official_telephone_number": "615-234-5954"
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": "FL",
            "license": "1204",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "075897300",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lake Mary, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 21, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • 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.