Provider Demographics
NPI:1265615124
Name:SOUTH LAKE HOSPITAL INC
Entity type:Organization
Organization Name:SOUTH LAKE HOSPITAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGACRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-237-6393
Mailing Address - Street 1:1900 DON WICKHAM DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1979
Mailing Address - Country:US
Mailing Address - Phone:352-241-7275
Mailing Address - Fax:352-241-7281
Practice Address - Street 1:1900 DON WICKHAM DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1979
Practice Address - Country:US
Practice Address - Phone:352-241-7275
Practice Address - Fax:352-241-7281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0051AMedicare PIN