| Entity Name: | LAKE MARY FAMILY PHYSICIANS P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 27 Jan 2005 (20 years ago) |
| Date of dissolution: | 23 Sep 2016 (8 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 23 Sep 2016 (8 years ago) |
| Document Number: | P05000014173 |
| FEI/EIN Number | 562499046 |
| Address: | 910 WILLISTON PARK POINT STE 2050, LAKE MARY, FL, 32746 |
| Mail Address: | 910 WILLISTON PARK POINT STE 2050, LAKE MARY, FL, 32746 |
| ZIP code: | 32746 |
| County: | Seminole |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1174719082 | 2007-09-25 | 2009-07-07 | 910 WILLISTON PARK PT, SUITE 2050, LAKE MARY, FL, 327462172, US | 910 WILLISTON PARK PT, SUITE 2050, LAKE MARY, FL, 327462172, US | |||||||||||||||||||||||||||||||||||||||
|
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| Phone | +1 407-829-8960 |
| Fax | 4078298978 |
Authorized person
| Name | MS. LEAH M SUTPHIN |
| Role | BILLING MANAGER |
| Phone | 4078298960 |
Taxonomy
| Taxonomy Code | 302F00000X - Exclusive Provider Organization |
| License Number | ME88467, ME88578 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 363L00000X - Nurse Practitioner |
| License Number | ARNP1103432 |
| State | FL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | BCBS OF FLORIDA |
| Number | 94986 |
| State | FL |
| Issuer | MEDICARE GROUP NUMBER |
| Number | K8696 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| MAGEE EDWARD J | Agent | 1719 SHADYREST COURT, LAKE MARY, FL, 32746 |
| Name | Role | Address |
|---|---|---|
| MAGEE EDWARD J | Director | 1719 SHADYREST COURT, LAKE MARY, FL, 32746 |
| MAGEE KRISTY JO M | Director | 1719 SHADYREST COURT, LAKE MARY, FL, 32746 |
| Name | Role | Address |
|---|---|---|
| MAGEE EDWARD J | President | 1719 SHADYREST COURT, LAKE MARY, FL, 32746 |
| Name | Role | Address |
|---|---|---|
| MAGEE EDWARD J | Treasurer | 1719 SHADYREST COURT, LAKE MARY, FL, 32746 |
| Name | Role | Address |
|---|---|---|
| MAGEE KRISTY JO M | Vice President | 1719 SHADYREST COURT, LAKE MARY, FL, 32746 |
| Name | Role | Address |
|---|---|---|
| MAGEE KRISTY JO M | Secretary | 1719 SHADYREST COURT, LAKE MARY, FL, 32746 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2016-09-23 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2007-04-30 | 1719 SHADYREST COURT, LAKE MARY, FL 32746 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2015-04-12 |
| ANNUAL REPORT | 2014-04-16 |
| ANNUAL REPORT | 2013-04-30 |
| ANNUAL REPORT | 2012-06-15 |
| ANNUAL REPORT | 2011-06-09 |
| ANNUAL REPORT | 2010-05-10 |
| ANNUAL REPORT | 2009-05-19 |
| ANNUAL REPORT | 2008-04-27 |
| ANNUAL REPORT | 2007-04-30 |
| ANNUAL REPORT | 2006-04-27 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
