Provider Demographics
NPI:1376710681
Name:EASTERN MEDICAL SPECIALISTS
Entity Type:Organization
Organization Name:EASTERN MEDICAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:P
Authorized Official - Last Name:RONK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-949-4446
Mailing Address - Street 1:48 MEDICAL PARK DR E
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235-3400
Mailing Address - Country:US
Mailing Address - Phone:205-949-4446
Mailing Address - Fax:205-838-3206
Practice Address - Street 1:150 GILBREATH DR
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:AL
Practice Address - Zip Code:35121-2827
Practice Address - Country:US
Practice Address - Phone:205-274-3344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10881207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009972390Medicaid
AL51503246OtherBLUE CROSS
ALC73649Medicare UPIN