1528275781 NPI number — EAST LAKE ONCOLOGY

Table of content: (NPI 1528275781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528275781 NPI number — EAST LAKE ONCOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST LAKE ONCOLOGY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528275781
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4114 WOODLANDS PKWY
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
PALM HARBOR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34685-3450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-789-2595
Provider Business Mailing Address Fax Number:
727-789-8891

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4114 WOODLANDS PKWY
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
PALM HARBOR
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34685-3450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-789-2595
Provider Business Practice Location Address Fax Number:
727-789-8891
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NORBERGS
Authorized Official First Name:
D.
Authorized Official Middle Name:
ANDA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
727-789-2595

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  ME0056118 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 09165 . This is a "BCBSFL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: DG4665 . This is a "RRW MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 09165Y . This is a "MEDICARE UNSPEC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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