| Countryside Medical PA | |
|
7860 Sw 103rd Street Rd Bldg 100 Suite 101 Ocala FL 34476-8623 | |
| (352) 873-4458 | |
| (352) 873-8116 |
| Full Name | Countryside Medical PA |
|---|---|
| Speciality | Internal Medicine |
| Location | 7860 Sw 103rd Street Rd, Ocala, Florida |
| Authorized Official Name and Position | Kenneth Baruch Lee (OWNER PRESIDENT) |
| Authorized Official Contact | 3528734458 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Countryside Medical PA Po Box 770719 Ocala FL 34477-0719 Ph: (352) 873-4458 | Countryside Medical PA 7860 Sw 103rd Street Rd Bldg 100 Suite 101 Ocala FL 34476-8623 Ph: (352) 873-4458 |
| NPI Number | 1275610362 |
|---|---|
| Provider Enumeration Date | 11/01/2006 |
| Last Update Date | 09/01/2023 |
| Certification Date | 09/01/2023 |
| Medicare PECOS PAC ID | 2860460318 |
|---|---|
| Medicare Enrollment ID | O20040922000438 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1275610362 | NPI | - | NPPES |
| CG9421 | Other | RR MEDICARE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | (NU) | Primary |
| Provider Name | Kenneth Lee |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1023195112 PECOS PAC ID: 3476521923 Enrollment ID: I20100719000309 |
| Provider Name | Clara L Kalil |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1528218971 PECOS PAC ID: 6002952686 Enrollment ID: I20161202000171 |
| Provider Name | Kayli a Taylor |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1801515416 PECOS PAC ID: 2567838881 Enrollment ID: I20221011002565 |
| Provider Name | Roberto Rodriguez Perez |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1184606618 PECOS PAC ID: 3870767379 Enrollment ID: I20240823000887 |
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