EAST LAKE MEDICAL CLINIC
NPI 1790124741
Clinic/Center - Primary Care in Saint Cloud, FL
About East Lake Medical Clinic NPPES
Official registry information on file with the National Plan and Provider Enumeration System.
EAST LAKE MEDICAL CLINIC (NPI 1790124741) is a healthcare organization registered as a primary care in Saint Cloud, Florida and active in the NPI registry since June 2013. The organization holds 2 active CLIA laboratory certificates and lists Dustin Ly, President, as its authorized official.
NPPES Registry Identity
Specialties & Licenses
Accepted Insurance
Medicare Participation & PECOS CMS
Medicare enrollment and the clinicians who bill Medicare through this organization, from CMS.
Medicare Enrollment Status
Enrolled in Medicare (PECOS)
East Lake Medical Clinic is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).
Clinicians Billing Medicare Through This Organization
5Medicare enrollment records show 5 clinicians reassign Medicare billing to East Lake Medical Clinic, which bills Medicare for the services they deliver. Of these, 1 practice at this address and 2 within 10 miles. They are listed nearest first.
Clinicians, nearest first (5)
Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
CLIA Laboratory Certificates CMS CLIA 2
Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.
Certificate of Waiver 10D2067792
East Lake Medical Clinic PLLC · Saint Cloud, FLCertificate of Waiver 10D2256891
East Lake Medical Clinic PA · Orlando, FLFrequently Asked Questions NPPES & CMS
Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.
What is East Lake Medical Clinic's NPI number?
The NPI number for East Lake Medical Clinic is 1790124741. It was assigned to this organization in the NPPES registry on June 21, 2013.
Where is East Lake Medical Clinic located?
East Lake Medical Clinic is located at 4737 Old Canoe Creek Rd, Saint Cloud, FL 34769. The listed phone number is (407) 705-3222.
What is East Lake Medical Clinic's specialty?
The primary specialty registered for this NPI is Clinic/Center, specializing in Primary Care, with taxonomy code 261QP2300X.
Is East Lake Medical Clinic enrolled in Medicare?
Yes. East Lake Medical Clinic is registered in the Medicare PECOS enrollment system.
How many clinicians bill Medicare through East Lake Medical Clinic?
According to the CMS Revalidation Reassignment List (October 2026 release), 5 clinicians in 3 Medicare specialties reassign their Medicare billing to East Lake Medical Clinic. A reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for the clinician's services. The largest specialties are Nurse Practitioner (3), General Practice (1) and Internal Medicine (1). Of these, 1 practice at this address and 2 within 10 miles. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
Does East Lake Medical Clinic hold CLIA laboratory certificates?
Yes. 2 active CLIA laboratory certificates are associated with this NPI under the federal Clinical Laboratory Improvement Amendments program. The certificates are listed in the CLIA Laboratory Certificates section above.
What insurance does East Lake Medical Clinic accept?
Health plans from Ambetter Health, Ambetter from Superior HealthPlan, Ambetter of Alabama and AvMed list East Lake Medical Clinic as in-network in at least one marketplace plan. Coverage varies by plan and year; verify with the insurer or the provider before a visit.
When was this NPI record last updated?
The NPPES record for East Lake Medical Clinic was last updated on June 21, 2013. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 13 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.
# East Lake Medical Clinic · NPI 1790124741
Primary Care organization in Saint Cloud, Florida. Organization record, active in the CMS NPPES registry since June 21, 2013.
## Identity
- **NPI:** 1790124741 (Entity type: Organization)
- **Enumerated:** June 21, 2013
- **Primary specialty:** Clinic/Center - Primary Care · taxonomy 261QP2300X
- **Organization subpart:** No
- **Authorized official:** Dustin Ly, PRESIDENT
## Practice location
- **Address:** 4737 OLD CANOE CREEK RD, Saint Cloud, FL 34769-1400
- **Phone:** (407) 705-3222
## Medicare
- **Medicare:** Enrolled in Medicare (PECOS)
- **Clinicians billing through this organization:** 5 clinicians in 3 Medicare specialties reassign Medicare billing to this organization (form CMS-855R); largest: Nurse Practitioner (3), General Practice (1), Internal Medicine (1); 1 practice at this address and 2 within 10 miles · CMS Revalidation Reassignment List, October 2026 release
## Record status
- **NPPES last updated:** June 21, 2013
- **CLIA laboratory certificates:** 2 on file
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Source: [NPI Profile](https://npiprofile.com/npi/1790124741) · Data from the CMS NPPES public registry.