Provider Demographics
NPI:1578922613
Name:LAKE CITY INSTITUTE OF NEUROLOGY PA
Entity type:Organization
Organization Name:LAKE CITY INSTITUTE OF NEUROLOGY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REKHA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIDADAVOLU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-905-9316
Mailing Address - Street 1:4745 OLD CANOE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-1400
Mailing Address - Country:US
Mailing Address - Phone:407-818-1664
Mailing Address - Fax:407-818-1654
Practice Address - Street 1:4745 OLD CANOE CREEK RD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-1400
Practice Address - Country:US
Practice Address - Phone:407-818-1664
Practice Address - Fax:407-818-1654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-17
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDS6851OtherRAILROAD MEDICARE
FL14H5XOtherBCBS
FL003957500Medicaid
FLFJ256AMedicare PIN