NPIMap

Organization Active NPI

Lake Erie College of Osteopathic Medicine

Doing business as Lecom - Englewood Family Practice

  • Family Medicine Physician
  • Englewood, FL
National Provider Identifier
1467087296
Registry record updated Mar 12, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE
Doing business as
Lecom - Englewood Family Practice
Practice address
2828 S McCall Rd Ste 21
Englewood, FL 34224-9517
Phone
(941) 474-8154
NPI assigned
Mar 12, 2020
Last updated
Mar 12, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 12, 2020

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

Authorized official

Name
Tatiana Robles
Title
Credentialing Cooridator
Phone
(239) 348-5080

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

2828 S McCall Rd Ste 21
Englewood, FL 34224-9517

Mailing address

2828 S McCall Rd Ste 21
Englewood, FL 34224-9517
Phone (941) 474-8154

Other names 1

  • LECOM - ENGLEWOOD FAMILY PRACTICE Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL athenahealth Health Information Exchange (HIE)

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200511002017 FL Part B Supplier - Clinic/Group Practice 7719141472 Receives reassigned benefits from 7 practitioners
Practice locations: Englewood, FL

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
10D2031274Lecom Englewood Family Practice2828 S McCall Rd Ste 21, Englewood, FL 34224Certificate of waiverOct 16, 2027

National Provider Directory

National Provider Directory

Member organizations 14

Organizations listed as members of this organization in the National Provider Directory.

View all 14

Locations

2828 S McCall Rd
Ste 22
Englewood, FL 34224
Phone (813) 475-6399

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1583971200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1583971200000",
    "number": "1467087296",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2828 S MCCALL RD STE 21",
            "city": "ENGLEWOOD",
            "state": "FL",
            "postal_code": "342249517",
            "telephone_number": "941-474-8154"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2828 S MCCALL RD STE 21",
            "city": "ENGLEWOOD",
            "state": "FL",
            "postal_code": "342249517",
            "telephone_number": "941-474-8154"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-03-12",
        "last_updated": "2020-03-12",
        "certification_date": "2020-03-12",
        "status": "A",
        "authorized_official_last_name": "ROBLES",
        "authorized_official_first_name": "TATIANA",
        "authorized_official_title_or_position": "CREDENTIALING COORIDATOR",
        "authorized_official_telephone_number": "239-348-5080"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "athenahealth",
            "affiliation": "N",
            "endpointDescription": "EMR",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "address_1": "2828 S McCall Rd Ste 21",
            "city": "Englewood",
            "state": "FL",
            "country_code": "US",
            "postal_code": "342249517",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "LECOM - ENGLEWOOD FAMILY PRACTICE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Englewood, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 12, 2020; 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.