Provider Demographics
NPI:1053613232
Name:SOUTH LAKE PRIMARY CARE P A
Entity type:Organization
Organization Name:SOUTH LAKE PRIMARY CARE P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:RAMON
Authorized Official - Middle Name:
Authorized Official - Last Name:SUEIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-243-3800
Mailing Address - Street 1:1503 SUNRISE PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34714-6200
Mailing Address - Country:US
Mailing Address - Phone:352-243-3800
Mailing Address - Fax:352-243-3804
Practice Address - Street 1:1503 SUNRISE PLAZA DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34714-6200
Practice Address - Country:US
Practice Address - Phone:352-243-3800
Practice Address - Fax:352-243-3804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-22
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0071348261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250594100Medicaid
FL250594100Medicaid
FLG35745Medicare UPIN