Provider Demographics
NPI:1407847676
Name:EASTSIDE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:EASTSIDE ASSOCIATES, LLC
Other - Org Name:EASTSIDE ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:VENERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-447-5112
Mailing Address - Street 1:28963 LITTLE MACK AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3015
Mailing Address - Country:US
Mailing Address - Phone:586-447-5110
Mailing Address - Fax:586-774-6091
Practice Address - Street 1:28963 LITTLE MACK AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-3015
Practice Address - Country:US
Practice Address - Phone:586-447-5110
Practice Address - Fax:586-774-6091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI506822261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI40358OtherBLUE CROSS ID NUMBER
MIOM25150Medicare ID - Type Unspecified