Provider Demographics
NPI:1174719082
Name:LAKE MARY FAMILY PHYSICIANS P.A.
Entity type:Organization
Organization Name:LAKE MARY FAMILY PHYSICIANS P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:M
Authorized Official - Last Name:SUTPHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-829-8960
Mailing Address - Street 1:910 WILLISTON PARK PT
Mailing Address - Street 2:SUITE 2050
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2172
Mailing Address - Country:US
Mailing Address - Phone:407-829-8960
Mailing Address - Fax:407-829-8978
Practice Address - Street 1:910 WILLISTON PARK PT
Practice Address - Street 2:SUITE 2050
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2172
Practice Address - Country:US
Practice Address - Phone:407-829-8960
Practice Address - Fax:407-829-8978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1103432363L00000X
FLME88467, ME88578302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302F00000XManaged Care OrganizationsExclusive Provider OrganizationGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL94986OtherBCBS OF FLORIDA
FLK8696OtherMEDICARE GROUP NUMBER
FLK8696OtherMEDICARE GROUP NUMBER
FL=========OtherFHHS
FL=========OtherAETNA
FL=========OtherCIGNA
FL94986OtherBCBS OF FLORIDA