Provider Demographics
NPI:1629384144
Name:EAST SIDE MEDICAL SERVICES P C
Entity Type:Organization
Organization Name:EAST SIDE MEDICAL SERVICES P C
Other - Org Name:EDGEWOOD CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHD
Authorized Official - Middle Name:S
Authorized Official - Last Name:JAFRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-445-3070
Mailing Address - Street 1:22790 HARPER AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1831
Mailing Address - Country:US
Mailing Address - Phone:586-445-3070
Mailing Address - Fax:586-445-3072
Practice Address - Street 1:22790 HARPER AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1831
Practice Address - Country:US
Practice Address - Phone:586-445-3070
Practice Address - Fax:586-445-3072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-21
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031532174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1285498Medicaid
MI35002138111Medicare PIN
MIB49012Medicare UPIN