Provider Demographics
NPI:1528063534
Name:LAKELAND MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:LAKELAND MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CE0
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:HEINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-676-3200
Mailing Address - Street 1:117 MEDICAL CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751
Mailing Address - Country:US
Mailing Address - Phone:903-676-3200
Mailing Address - Fax:903-676-3277
Practice Address - Street 1:117 MEDICAL CIRCLE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751
Practice Address - Country:US
Practice Address - Phone:903-676-3200
Practice Address - Fax:903-676-3277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0239207Q00000X
TXG3099207Q00000X
TXJ4022207Q00000X
ARC5043207Q00000X
TXG1367207Q00000X
TXG2988207Q00000X
TXH6314207Q00000X
TXL1095207Q00000X
TXE4479207Q00000X
TXF6042207Q00000X
ARC4956207Q00000X
TXL0856207Q00000X
TXE7871207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00D969OtherBCBS GROUP NUMBER
TX111549503Medicaid
TX111549502Medicaid