Provider Demographics
NPI:1437211703
Name:EASTSIDE INTERNAL MEDICINE, LLC
Entity Type:Organization
Organization Name:EASTSIDE INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SYED
Authorized Official - Middle Name:
Authorized Official - Last Name:WASIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-625-7800
Mailing Address - Street 1:2080 EASTSIDE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-1953
Mailing Address - Country:US
Mailing Address - Phone:678-625-7800
Mailing Address - Fax:678-625-7888
Practice Address - Street 1:2080 EASTSIDE DR
Practice Address - Street 2:SUITE A
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-1953
Practice Address - Country:US
Practice Address - Phone:678-625-7800
Practice Address - Fax:678-625-7888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1093773905OtherNPI NUMBER
GA1992763809OtherNPI NUMBER
GA1871551788OtherNPI NUMBER