Provider Demographics
NPI:1013128420
Name:EASTCOAST MEDICAL NETWORK INC
Entity type:Organization
Organization Name:EASTCOAST MEDICAL NETWORK INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:J
Authorized Official - Last Name:STAFFELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-648-5252
Mailing Address - Street 1:6000 TURKEY LAKE RD STE 209
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-4206
Mailing Address - Country:US
Mailing Address - Phone:407-648-5252
Mailing Address - Fax:407-370-4126
Practice Address - Street 1:6000 TURKEY LAKE RD STE 208
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-4206
Practice Address - Country:US
Practice Address - Phone:407-648-5252
Practice Address - Fax:407-370-4126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL98731Medicare ID - Type Unspecified