Provider Demographics
NPI:1346427291
Name:EASTLAKE RADIOLOGY LLC
Entity Type:Organization
Organization Name:EASTLAKE RADIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:VOGELPOHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-585-6265
Mailing Address - Street 1:11605 FM 1960 E
Mailing Address - Street 2:
Mailing Address - City:HUFFMAN
Mailing Address - State:TX
Mailing Address - Zip Code:77336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11605 FM 1960 E
Practice Address - Street 2:
Practice Address - City:HUFFMAN
Practice Address - State:TX
Practice Address - Zip Code:77336
Practice Address - Country:US
Practice Address - Phone:877-839-9517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00699983OtherRAILROAD MEDICARE
TX0678DCOtherBCBS OF TEXAS
TXFTX266Medicare PIN