Provider Demographics
NPI:1659413839
Name:EASTGLEN PEDIATRICS, INC.
Entity Type:Organization
Organization Name:EASTGLEN PEDIATRICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:L.
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:POLSTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-866-8077
Mailing Address - Street 1:6495 E BROAD ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1541
Mailing Address - Country:US
Mailing Address - Phone:614-866-8077
Mailing Address - Fax:614-866-9752
Practice Address - Street 1:6495 E BROAD ST
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1541
Practice Address - Country:US
Practice Address - Phone:614-866-8077
Practice Address - Fax:614-866-9752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35031032261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0222244Medicaid