Provider Demographics
NPI:1609951870
Name:EASTSIDE CT
Entity Type:Organization
Organization Name:EASTSIDE CT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-743-9130
Mailing Address - Street 1:1198 N BELSAY RD BLDG 2
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1669
Mailing Address - Country:US
Mailing Address - Phone:810-743-9130
Mailing Address - Fax:810-743-3203
Practice Address - Street 1:1198 N BELSAY RD BLDG 2
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1669
Practice Address - Country:US
Practice Address - Phone:810-743-9130
Practice Address - Fax:810-743-3202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIO B5 6177OtherBCBS PROVIDER CODE
MI3078222OtherHEALTH PLUS PROVIDER NO.
MIOB56177Medicare ID - Type Unspecified