Provider Demographics
NPI:1578503348
Name:EASTSIDE MEDICINE, LLC
Entity Type:Organization
Organization Name:EASTSIDE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-982-9450
Mailing Address - Street 1:1800 TREE LN
Mailing Address - Street 2:SUITE 270
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2016
Mailing Address - Country:US
Mailing Address - Phone:770-982-9450
Mailing Address - Fax:
Practice Address - Street 1:1800 TREE LN
Practice Address - Street 2:SUITE 270
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2016
Practice Address - Country:US
Practice Address - Phone:770-982-9450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6718Medicare UPIN