Provider Demographics
NPI:1861493199
Name:EASTSIDE CARDIOVASCULAR MEDICINE, P.C.
Entity Type:Organization
Organization Name:EASTSIDE CARDIOVASCULAR MEDICINE, P.C.
Other - Org Name:EASTSIDE CARDIOLOGY PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/EASTSIDE CARDIOVASCULAR M
Authorized Official - Prefix:
Authorized Official - First Name:VAMSHIDHAR
Authorized Official - Middle Name:D
Authorized Official - Last Name:GUDUGUNTIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-775-4594
Mailing Address - Street 1:25195 KELLY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4909
Mailing Address - Country:US
Mailing Address - Phone:586-775-4594
Mailing Address - Fax:586-775-4506
Practice Address - Street 1:25195 KELLY ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4909
Practice Address - Country:US
Practice Address - Phone:586-775-4594
Practice Address - Fax:586-775-4506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI060E01111OtherBLUE CROSS BLUE SHIELD
MIOH-264673061Medicare PIN