Provider Demographics
NPI:1598899395
Name:EASTSIDE VENTURES, INC.
Entity Type:Organization
Organization Name:EASTSIDE VENTURES, INC.
Other - Org Name:ONEONTA INTERNAL MEDICINE AND PEDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:H
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:205-838-3718
Mailing Address - Street 1:150 GILBREATH DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ONEONTA
Mailing Address - State:AL
Mailing Address - Zip Code:35121-2827
Mailing Address - Country:US
Mailing Address - Phone:205-625-5711
Mailing Address - Fax:
Practice Address - Street 1:150 GILBREATH DR
Practice Address - Street 2:SUITE 201
Practice Address - City:ONEONTA
Practice Address - State:AL
Practice Address - Zip Code:35121-2827
Practice Address - Country:US
Practice Address - Phone:205-625-5711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529703050Medicaid
E893OtherMEDICARE PT B