Provider Demographics
NPI:1477589158
Name:EASTRIDGE FAMILY MEDICINE
Entity Type:Organization
Organization Name:EASTRIDGE FAMILY MEDICINE
Other - Org Name:EASTRIDGE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENTERPRISE EVP
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:RISSMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-8675
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:704-631-0002
Mailing Address - Fax:
Practice Address - Street 1:1896 REMOUNT RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7414
Practice Address - Country:US
Practice Address - Phone:704-512-3930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTRIDGE FAMILY MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-24
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPA741Medicaid
NC890131HMedicaid
NC2329525Medicare ID - Type UnspecifiedGORUP NUMBER