Provider Demographics
NPI:1144377821
Name:EASTSIDE PODIATRY PLLC
Entity Type:Organization
Organization Name:EASTSIDE PODIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HATIM
Authorized Official - Middle Name:TAHIR
Authorized Official - Last Name:BURHANI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:313-884-7566
Mailing Address - Street 1:24025 GREATER MACK
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ST. CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-4311
Mailing Address - Country:US
Mailing Address - Phone:313-884-7566
Mailing Address - Fax:313-884-3140
Practice Address - Street 1:24025 GREATER MACK
Practice Address - Street 2:SUITE 101
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080
Practice Address - Country:US
Practice Address - Phone:313-884-7566
Practice Address - Fax:313-884-3140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002021213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4476009Medicaid
MIU86243Medicare UPIN
MI0N92390Medicare ID - Type Unspecified
MI4476009Medicaid