Provider Demographics
NPI:1043496359
Name:EAST SIDE SURGICAL GROUP INC
Entity Type:Organization
Organization Name:EAST SIDE SURGICAL GROUP INC
Other - Org Name:BREAST HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:I
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-312-0023
Mailing Address - Street 1:407 EAST AVENUE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-5299
Mailing Address - Country:US
Mailing Address - Phone:401-312-0023
Mailing Address - Fax:401-312-0006
Practice Address - Street 1:407 EAST AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-5299
Practice Address - Country:US
Practice Address - Phone:401-312-0023
Practice Address - Fax:401-312-0006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI5011174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
709006205Medicare PIN