Provider Demographics
NPI:1174564553
Name:LAKELAND PHYSICIANS GROUP LLC
Entity type:Organization
Organization Name:LAKELAND PHYSICIANS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:NIMBARGI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-782-3702
Mailing Address - Street 1:PO BOX 150038
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32715-0038
Mailing Address - Country:US
Mailing Address - Phone:407-782-3702
Mailing Address - Fax:863-648-9520
Practice Address - Street 1:517 BUENA VISTA ST.
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805
Practice Address - Country:US
Practice Address - Phone:863-688-3674
Practice Address - Fax:863-616-9902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85807174400000X
FLME92618174400000X
207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275444400Medicaid
FL72117OtherBCBS
FLDG9369OtherRAILROAD MEDICARE
FL113345OtherAMERIGROUP
FL265742201Medicaid
FL5324701OtherAETNA
FLDG9369OtherRAILROAD MEDICARE
FLAB171Medicare PIN
FLAB170ZMedicare PIN
FL5324701OtherAETNA
FL275444400Medicaid