MEDICARE: LAKE CITY INSTITUTE OF NEUROLOGY PA

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	2084N0008X	Neuromuscular Medicine (Psychiatry & Neurology) Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DS6851	OTHER	FL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	14H5X	OTHER	FL	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578922613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE CITY INSTITUTE OF NEUROLOGY PA

Provider Business Mailing Address
First Line	:	4745 OLD CANOE CREEK RD
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-1400
Country	:	US
Telephone Number	:	407-818-1664
Fax Number	:	407-818-1654

Provider Business Practice Location Address
First Line	:	4745 OLD CANOE CREEK RD
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-1400
Country	:	US
Telephone Number	:	407-818-1664
Fax Number	:	407-818-1654

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. REKHA NIDADAVOLU
Credential	:
Telephone Number	:	305-905-9316

Provider Enumeration Date	:	02/17/2016
Last Update Date	:	01/09/2025

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Directions to “LAKE CITY INSTITUTE OF NEUROLOGY PA ” Practice Location

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