Provider Demographics
NPI:1225640329
Name:EASTSIDE DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:EASTSIDE DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:248-709-7072
Mailing Address - Street 1:22000 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2500
Mailing Address - Country:US
Mailing Address - Phone:248-709-7072
Mailing Address - Fax:
Practice Address - Street 1:25100 KELLY RD STE B
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4910
Practice Address - Country:US
Practice Address - Phone:248-262-7379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAXIM L.L.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile