1437211703 NPI number — EASTSIDE INTERNAL MEDICINE, LLC

Table of content: (NPI 1437211703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437211703 NPI number — EASTSIDE INTERNAL MEDICINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTSIDE INTERNAL MEDICINE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437211703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2080 EASTSIDE DR
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
CONYERS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30013-1953
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-625-7800
Provider Business Mailing Address Fax Number:
678-625-7888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2080 EASTSIDE DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
CONYERS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30013-1953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-625-7800
Provider Business Practice Location Address Fax Number:
678-625-7888
Provider Enumeration Date:
12/14/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WASIM
Authorized Official First Name:
SYED
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
678-625-7800

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1093773905 . This is a "NPI NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1992763809 . This is a "NPI NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1871551788 . This is a "NPI NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".