Provider Demographics
NPI:1023295193
Name:EASTSIDE CLINIC
Entity type:Organization
Organization Name:EASTSIDE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:SERATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-456-6250
Mailing Address - Street 1:PO BOX 59
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-0059
Mailing Address - Country:US
Mailing Address - Phone:918-456-6250
Mailing Address - Fax:918-456-4080
Practice Address - Street 1:22408 HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2058
Practice Address - Country:US
Practice Address - Phone:918-456-6250
Practice Address - Fax:918-456-4080
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTSIDE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-30
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15674207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK4111208OtherAETNA
OKC95468OtherUPIN
OK110118510AMedicaid
OK445569081002OtherBLUECROSS AND BLUESHIELD
OKC95468OtherUPIN
OK=========OtherHEALTHCHOICE