MEDICARE: STEVEN CHARLES EASTLACK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	2025-01804	NC
2	207L00000X	Anesthesiology Physician	13865872-1205	UT

General Provider Information

NPI Number	:	1417578709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEVEN CHARLES EASTLACK MD

Provider Business Mailing Address
First Line	:	100 KIMEL FOREST DR
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-6074
Country	:	US
Telephone Number	:	336-716-2255
Fax Number	:

Provider Business Practice Location Address
First Line	:	MEDICAL CENTER BLVD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27157-0001
Country	:	US
Telephone Number	:	336-716-3245
Fax Number	:	336-716-0567

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2020
Last Update Date	:	02/02/2026

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