Organization Name: | EASTSIDE ASSOCIATES, LLC |
NPI Number: | 1407847676 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | FERNANDO BERMUDEZ (MEDICAL DIRECTOR) |
Mailing Address: | 28963 Little Mack Ave Suite 103 St Clair Shores |
State: | MI US |
Postal Code: | 480813015 |
Phone Number: | 5864475110 |
Fax Number: | 5867746091 |
NPI Enumeration Date: | 11/04/2005 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QE0800X |
License Number: | 506822 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MI |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Endoscopy |
Taxonomy Definition: |