1467406132 NPI number — EASTSIDE MEDICAL CENTER, LLC

Table of content: (NPI 1467406132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467406132 NPI number — EASTSIDE MEDICAL CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTSIDE MEDICAL CENTER, 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:
6
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:
1467406132
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 MEDICAL WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SNELLVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30078-2195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-979-0200
Provider Business Mailing Address Fax Number:
770-736-2395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 MEDICAL WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SNELLVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30078-2195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-979-0200
Provider Business Practice Location Address Fax Number:
770-736-2395
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CROSS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
C
Authorized Official Title or Position:
VP GOVERNMENT REIMBURSEMENT
Authorized Official Telephone Number:
470-271-3401

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00190088A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 158328200 . This is a "DEPT OF LABOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 30000595 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 406635900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 071850401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82176800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 157505105 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 308068059 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 143405 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200225640A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82092 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: HOS0192N , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0067598 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0110192 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1526531 . This is a "GATEWAY MEDICAID HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1633343 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3564 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4001267 . This is a "BLUE CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 421810000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: XHSP33294 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com