Provider Demographics
NPI:1528045135
Name:EASTSIDE MEDICAL URGENT CARE, LLC
Entity Type:Organization
Organization Name:EASTSIDE MEDICAL URGENT CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAHMTAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HORMOZDYARAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-388-5280
Mailing Address - Street 1:2226 PENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526-1922
Mailing Address - Country:US
Mailing Address - Phone:585-388-5280
Mailing Address - Fax:585-388-5282
Practice Address - Street 1:2226 PENFIELD RD
Practice Address - Street 2:
Practice Address - City:PENFIELD
Practice Address - State:NY
Practice Address - Zip Code:14526-1922
Practice Address - Country:US
Practice Address - Phone:585-388-5280
Practice Address - Fax:585-388-5282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-23
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213296261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID