Provider Demographics
NPI:1174727937
Name:FLORIDA LAKES SURGICAL PLLC
Entity type:Organization
Organization Name:FLORIDA LAKES SURGICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:LACKEY
Authorized Official - Suffix:II
Authorized Official - Credentials:DO
Authorized Official - Phone:8634-026-5600
Mailing Address - Street 1:4751 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-2064
Mailing Address - Country:US
Mailing Address - Phone:863-402-5600
Mailing Address - Fax:863-402-5602
Practice Address - Street 1:4751 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-2064
Practice Address - Country:US
Practice Address - Phone:863-402-5600
Practice Address - Fax:863-402-5602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279537000Medicaid
FLAF613Medicare PIN