Provider Demographics
NPI:1619925070
Name:EASTSIDE P.E.T. CENTER, LLC
Entity Type:Organization
Organization Name:EASTSIDE P.E.T. CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:CPCD
Authorized Official - Phone:205-221-8258
Mailing Address - Street 1:406 MEDICAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-3400
Mailing Address - Country:US
Mailing Address - Phone:205-221-8200
Mailing Address - Fax:205-221-8270
Practice Address - Street 1:46 MEDICAL PARK DR. E.
Practice Address - Street 2:STE. 224
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3401
Practice Address - Country:US
Practice Address - Phone:205-838-3738
Practice Address - Fax:205-838-6738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051558430Medicaid