# LAKELAND REGIONAL HEALTH SYSTEM, INC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1114393469
- **Authorized official:** LANCE GREEN (CFO)
- **Authorized official phone:** (863) 687-1100

## Contact information

- **Practice address:** 3644 INNOVATION DR, LAKELAND, FL 33812-4105
- **Practice address phone:** (863) 284-1583
- **Practice address fax:** (863) 413-4822
- **Mailing address:** 1324 LAKELAND HILLS BLVD, MANAGED CARE DEPT, LAKELAND, FL 33805
- **Mailing address phone:** (863) 687-1100
- **Mailing address fax:** (863) 630-6528

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207VF0040X | Urogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician | — | — | — |
| 208D00000X | General Practice Physician | — | — | Yes |
| 261QM1300X | Multi-Specialty Clinic/Center | — | — | — |
| 363A00000X | Physician Assistant | — | — | — |
| 363AS0400X | Surgical Physician Assistant | — | — | — |

## Other

- **Enumeration date:** 08/20/2015
- **Last updated:** 04/10/2023

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 263421022 | — | FL |