Healthcare Provider Details

I. General information

NPI: 1013128420
Provider Name (Legal Business Name): EASTCOAST MEDICAL NETWORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 TURKEY LAKE RD STE 208
ORLANDO FL
32819-4206
US

IV. Provider business mailing address

6000 TURKEY LAKE RD STE 209
ORLANDO FL
32819-4206
US

V. Phone/Fax

Practice location:
  • Phone: 407-648-5252
  • Fax: 407-370-4126
Mailing address:
  • Phone: 407-648-5252
  • Fax: 407-370-4126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELISSA J STAFFELLI
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 407-648-5252