1861493199 NPI number — EASTSIDE CARDIOVASCULAR MEDICINE, P.C.

Table of content: (NPI 1861493199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861493199 NPI number — EASTSIDE CARDIOVASCULAR MEDICINE, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTSIDE CARDIOVASCULAR MEDICINE, P.C.
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:
EASTSIDE CARDIOLOGY PC
Provider Other Organization Name Type Code:
4
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:
1861493199
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25195 KELLY RD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48066-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-775-4594
Provider Business Mailing Address Fax Number:
586-775-4506

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25195 KELLY ROAD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48066-4909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-775-4594
Provider Business Practice Location Address Fax Number:
586-775-4506
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GUDUGUNTIA
Authorized Official First Name:
VAMSHIDHAR
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT/EASTSIDE CARDIOVASCULAR M
Authorized Official Telephone Number:
586-775-4594

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 060E01111 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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