Provider Demographics
NPI:1376735316
Name:EASTLAKE MEDICAL CENTER PA
Entity Type:Organization
Organization Name:EASTLAKE MEDICAL CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAUNK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-789-6551
Mailing Address - Street 1:2595 TAMPA RD
Mailing Address - Street 2:STE K
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684
Mailing Address - Country:US
Mailing Address - Phone:727-789-6551
Mailing Address - Fax:
Practice Address - Street 1:2595 TAMPA RD
Practice Address - Street 2:STE K
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3152
Practice Address - Country:US
Practice Address - Phone:727-789-6551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0064536207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23400AMedicare PIN