Provider Demographics
NPI:1225567928
Name:EASTSIDE ORTHOPEDICS & SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:EASTSIDE ORTHOPEDICS & SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:S
Authorized Official - Last Name:TOMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-659-1964
Mailing Address - Street 1:6542 SE LAKE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2245
Mailing Address - Country:US
Mailing Address - Phone:503-659-1769
Mailing Address - Fax:503-659-7522
Practice Address - Street 1:6542 SE LAKE RD STE 201
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2245
Practice Address - Country:US
Practice Address - Phone:503-659-1769
Practice Address - Fax:503-659-7522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD183085207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Multi-Specialty