Provider Demographics
NPI:1437298999
Name:EASTSIDE FAMILY PRACTICE, INC.
Entity Type:Organization
Organization Name:EASTSIDE FAMILY PRACTICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRAESSER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:614-864-6107
Mailing Address - Street 1:1835 DRUGAN CT SW
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-8181
Mailing Address - Country:US
Mailing Address - Phone:614-864-6107
Mailing Address - Fax:
Practice Address - Street 1:11299 STONECREEK DR
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-8910
Practice Address - Country:US
Practice Address - Phone:614-235-4782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004238207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0722061Medicaid
OHEA9927911Medicare ID - Type UnspecifiedGROUP #