MEDICARE: EAST LAKE ONCOLOGY

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	207RH0003X	Hematology & Oncology Physician	ME0056118	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	DG4665	OTHER		RRW MEDICARE
3	09165Y	OTHER	FL	MEDICARE UNSPEC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	09165	OTHER	FL	BCBSFL

General Provider Information

NPI Number	:	1528275781
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST LAKE ONCOLOGY

Provider Business Mailing Address
First Line	:	4114 WOODLANDS PKWY
Second Line	:	SUITE 301
City	:	PALM HARBOR
State	:	FL
Zip	:	34685-3450
Country	:	US
Telephone Number	:	727-789-2595
Fax Number	:	727-789-8891

Provider Business Practice Location Address
First Line	:	4114 WOODLANDS PKWY
Second Line	:	SUITE 301
City	:	PALM HARBOR
State	:	FL
Zip	:	34685-3450
Country	:	US
Telephone Number	:	727-789-2595
Fax Number	:	727-789-8891

Authorized Official
Title or Position	:	PRESIDENT
Name	:	D. ANDA NORBERGS
Credential	:	M.D.
Telephone Number	:	727-789-2595

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	01/28/2008

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Directions to “EAST LAKE ONCOLOGY ” Practice Location

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