Provider Demographics
NPI:1861676306
Name:EASTSIDE VASCULAR MEDICINE AND SURGERY, P.C.
Entity Type:Organization
Organization Name:EASTSIDE VASCULAR MEDICINE AND SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUNAID
Authorized Official - Middle Name:HUSSAIN
Authorized Official - Last Name:MUDALIAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-684-1040
Mailing Address - Street 1:1700 TREE LANE RD
Mailing Address - Street 2:SUITE 460
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6782
Mailing Address - Country:US
Mailing Address - Phone:678-684-1040
Mailing Address - Fax:678-684-1045
Practice Address - Street 1:1700 TREE LANE RD
Practice Address - Street 2:SUITE 460
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6782
Practice Address - Country:US
Practice Address - Phone:678-684-1040
Practice Address - Fax:678-684-1045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050323174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7073Medicare PIN