Lake Wales Medical Walk in Clinic PA

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

License

ME87271 Issued in FL

Legal business name

LAKE WALES MEDICAL WALK IN CLINIC PA

Practice address

1611 State Road 60 E
Lake Wales, FL 33853-4309

Phone

(863) 676-6007

Fax

(863) 676-7659

NPI assigned

May 27, 2006

Organization subpart

No

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

Authorized official

Name

Ms. Susan Allen

Title

Office Manager

Phone

(863) 676-6007

Specialties & licenses 1

Addresses

Other identifiers 5

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

{
    "created_epoch": "1148688000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1360108800000",
    "number": "1336196278",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1611 STATE ROAD 60 E",
            "city": "LAKE WALES",
            "state": "FL",
            "postal_code": "338534309",
            "telephone_number": "863-676-6007",
            "fax_number": "863-676-7659"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1611 STATE ROAD 60 E",
            "city": "LAKE WALES",
            "state": "FL",
            "postal_code": "338534309",
            "telephone_number": "863-676-6007",
            "fax_number": "863-676-7659"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE WALES MEDICAL WALK IN CLINIC PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-27",
        "last_updated": "2013-02-06",
        "status": "A",
        "authorized_official_last_name": "ALLEN",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "863-676-6007",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": "FL",
            "license": "ME87271",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "265413000",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHEILD FL",
            "identifier": "97246",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DEPARTMENT OF LABOR OWCP",
            "identifier": "159572100",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HUMANA",
            "identifier": "000005600",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA HEALTH MGMT LLC",
            "identifier": "3499276",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Lake Wales Healthcare LLC (Grace Healthcare of Lake Wales)
• Lake Wales Hospital Corporation (Lake Wales Medical Center)
• Lake Wales Hospital Corporation (Lake Wales Medical Center)
• Lake Wales Medial Center
• Lake Wales Medical Imaging Center One, Inc
• Lake Wales Operating Group LLC
• Lake Wales Physician Services, LLC
• Lake Wales Primary Care Center, LLC
• Lake Wales SLC Opco LLC (The Club at Lakes Wales)
• Lake Wales SNF LLC

• Internal Medicine Physician in Lake Wales, FL
• Providers in Lake Wales, FL by specialty
• Internal Medicine Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 6, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.