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  5. SOUTH LAKE PEDIATRICS, P.A.

SOUTH LAKE PEDIATRICS, P.A.

Company Details

Entity Name: SOUTH LAKE PEDIATRICS, P.A.
Jurisdiction: FLORIDA
Filing Type: Domestic Profit
Status: Inactive
Date Filed: 26 Oct 2000 (24 years ago)
Date of dissolution: 31 Jan 2022 (3 years ago)
Last Event: VOLUNTARY DISSOLUTION
Event Date Filed: 31 Jan 2022 (3 years ago)
Document Number: P00000101069
FEI/EIN Number 593677418
Address: SOUTH LAKE PEDIATRICS, P.A., 8048 Horse Ferry Road, Orlando, FL, 32835, US
Mail Address: SOUTH LAKE PEDIATRICS, P.A., 8048 Horse Ferry Road, Orlando, FL, 32835, US
ZIP code: 32835
County: Orange
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1699076901 2010-11-03 2010-11-03 3155 CITRUS TOWER BLVD, BLDG.# 1, CLERMONT, FL, 347116803, US 3155 CITRUS TOWER BLVD, BLDG.# 1, CLERMONT, FL, 347116803, US

Contacts
Phone +1 352-242-1500
Fax 3522420053

Authorized person
Name DR. ADINARAYANAMURTHY NALLAMSHETTY
Role PRESIDENT
Phone 3522421500

Taxonomy
Taxonomy Code 208000000X - Pediatrics Physician
License Number ME073750
State FL
Is Primary Yes

Other Provider Identifiers
Issuer MEDICAID
Number 260240700
State FL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
SOUTH LAKE PEDIATRICS, P.A. RETIREMENT AND SAVINGS PLAN 2016 593677418 2017-04-20 SOUTH LAKE PEDIATRICS, P.A. 9
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2003-01-01
Business code 621111
Sponsor’s telephone number 3522421500
Plan sponsor’s address 3155 CITRUS TOWER BLVD., BLDG 1, CLERMONT, FL, 34711

Signature of
Role Plan administrator
Date 2017-04-19
Name of individual signing ADI NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2017-04-19
Name of individual signing ADI NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature
SOUTH LAKE PEDIATRICS, P.A. RETIREMENT AND SAVINGS PLAN 2016 593677418 2017-11-15 SOUTH LAKE PEDIATRICS, P.A. 9
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2003-01-01
Business code 621111
Sponsor’s telephone number 3522421500
Plan sponsor’s address 3155 CITRUS TOWER BLVD., BLDG 1, CLERMONT, FL, 34711
SOUTH LAKE PEDIATRICS, P.A. RETIREMENT AND SAVINGS PLAN 2015 593677418 2016-08-11 SOUTH LAKE PEDIATRICS, P.A. 9
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2003-01-01
Business code 621111
Sponsor’s telephone number 3522421500
Plan sponsor’s address 3155 CITRUS TOWER BLVD., #1, CLERMONT, FL, 34711

Signature of
Role Plan administrator
Date 2016-08-11
Name of individual signing ADI NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2016-08-11
Name of individual signing ADI NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature
SOUTH LAKE PEDIATRICS, P.A. RETIREMENT AND SAVINGS PLAN 2014 593677418 2015-06-24 SOUTH LAKE PEDIATRICS, P.A. 10
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2003-01-01
Business code 621111
Sponsor’s telephone number 3522421500
Plan sponsor’s address 3155 CITRUS TOWER BLVD., BLDG 1, CLERMONT, FL, 34711

Signature of
Role Plan administrator
Date 2015-06-18
Name of individual signing ADI NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2015-06-18
Name of individual signing ADI NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature
SOUTH LAKE PEDIATRICS, P.A. RETIREMENT AND SAVINGS PLAN 2013 593677418 2014-07-03 SOUTH LAKE PEDIATRICS, P.A. 8
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2003-01-01
Business code 621111
Sponsor’s telephone number 3522421500
Plan sponsor’s address 3155 CITRUS TOWER BLVD., BLDG 1, CLERMONT, FL, 34711

Signature of
Role Plan administrator
Date 2014-07-02
Name of individual signing ADI NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2014-07-02
Name of individual signing ADI NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature
SOUTH LAKE PEDIATRICS, P.A. RETIREMENT AND SAVINGS PLAN 2012 593677418 2013-07-19 SOUTH LAKE PEDIATRICS, P.A. 9
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2003-01-01
Business code 621111
Sponsor’s telephone number 3522421500
Plan sponsor’s address 3155 CITRUS TOWER BLVD., BLDG 1, CLERMONT, FL, 34711

Signature of
Role Plan administrator
Date 2013-07-18
Name of individual signing ADI NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2013-07-18
Name of individual signing ADI NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature
SOUTH LAKE PEDIATRICS, P.A. RETIREMENT AND SAVINGS PLAN 2011 593677418 2012-07-31 SOUTH LAKE PEDIATRICS, P.A. 10
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2003-01-01
Business code 621111
Sponsor’s telephone number 3522421500
Plan sponsor’s address 3155 CITRUS TOWER BLVD., BLDG 1, CLERMONT, FL, 34711

Plan administrator’s name and address
Administrator’s EIN 593677418
Plan administrator’s name SOUTH LAKE PEDIATRICS, P.A.
Plan administrator’s address 3155 CITRUS TOWER BLVD., BLDG 1, CLERMONT, FL, 34711
Administrator’s telephone number 3522421500

Signature of
Role Plan administrator
Date 2012-07-31
Name of individual signing ADINARAYANAMURTHY V NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2012-07-31
Name of individual signing ADINARAYANAMURTHY V NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature
SOUTH LAKE PEDIATRICS, P.A. RETIREMENT AND SAVINGS PLAN 2010 593677418 2011-09-20 SOUTH LAKE PEDIATRICS, P.A. 10
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2003-01-01
Business code 621111
Sponsor’s telephone number 3522421500
Plan sponsor’s address 3155 CITRUS TOWER BLVD., BLDG 1, CLERMONT, FL, 34711

Plan administrator’s name and address
Administrator’s EIN 593677418
Plan administrator’s name SOUTH LAKE PEDIATRICS, P.A.
Plan administrator’s address 3155 CITRUS TOWER BLVD., BLDG 1, CLERMONT, FL, 34711
Administrator’s telephone number 3522421500

Signature of
Role Plan administrator
Date 2011-09-19
Name of individual signing ADI NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-09-19
Name of individual signing ADI NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature
SOUTH LAKE PEDIATRICS, P.A. RETIREMENT AND SAVINGS PLAN 2010 593677418 2011-06-20 SOUTH LAKE PEDIATRICS, P.A. 10
Three-digit plan number (PN) 002
Effective date of plan 2003-01-01
Business code 621111
Sponsor’s telephone number 3522421500
Plan sponsor’s address 3155 CITRUS TOWER BLVD., BLDG 1, CLERMONT, FL, 34711

Plan administrator’s name and address
Administrator’s EIN 593677418
Plan administrator’s name SOUTH LAKE PEDIATRICS, P.A.
Plan administrator’s address 3155 CITRUS TOWER BLVD., BLDG 1, CLERMONT, FL, 34711
Administrator’s telephone number 3522421500

Signature of
Role Plan administrator
Date 2011-06-19
Name of individual signing ADINARAYANAMURTHY NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-06-19
Name of individual signing ADINARAYANAMURTHY NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature
SOUTH LAKE PEDIATRICS, P.A. RETIREMENT AND SAVINGS PLAN 2009 593677418 2010-07-16 SOUTH LAKE PEDIATRICS, P.A. 8
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2003-01-01
Business code 621111
Sponsor’s telephone number 3522421500
Plan sponsor’s address 3155 CITRUS TOWER BLVD., BLDG 1, CLERMONT, FL, 34711

Plan administrator’s name and address
Administrator’s EIN 593677418
Plan administrator’s name SOUTH LAKE PEDIATRICS, P.A.
Plan administrator’s address 3155 CITRUS TOWER BLVD., BLDG 1, CLERMONT, FL, 34711
Administrator’s telephone number 3522421500

Signature of
Role Plan administrator
Date 2010-07-16
Name of individual signing ADI NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2010-07-16
Name of individual signing ADI NALLAMSHETTY
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
NALLAMSHETTY ADINARAYANAMUR Agent 8048 Horse Ferry Road, Orlando, FL, 32835

Director

Name Role Address
NALLAMSHETTY ADINARAYANAMUR Director 8048 Horse Ferry Road, Orlando, FL, 32835

Events

Event Type Filed Date Value Description
VOLUNTARY DISSOLUTION 2022-01-31 No data No data
CHANGE OF PRINCIPAL ADDRESS 2021-01-12 SOUTH LAKE PEDIATRICS, P.A., 8048 Horse Ferry Road, Orlando, FL 32835 No data
REGISTERED AGENT ADDRESS CHANGED 2021-01-12 8048 Horse Ferry Road, Orlando, FL 32835 No data
CHANGE OF MAILING ADDRESS 2020-01-30 SOUTH LAKE PEDIATRICS, P.A., 8048 Horse Ferry Road, Orlando, FL 32835 No data

Documents

Name Date
VOLUNTARY DISSOLUTION 2022-01-31
ANNUAL REPORT 2021-01-12
ANNUAL REPORT 2020-01-30
ANNUAL REPORT 2019-01-28
ANNUAL REPORT 2018-01-12
ANNUAL REPORT 2017-01-10
ANNUAL REPORT 2016-03-04
ANNUAL REPORT 2015-01-13
ANNUAL REPORT 2014-01-19
ANNUAL REPORT 2013-05-16

Related by officers

NALLAMSHETTY ADINARAYANAMUR

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Related by address

No related companies by address

Date of last update: 03 Feb 2025

Sources: Florida Department of State

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