Provider Demographics
NPI:1134212319
Name:EASTSIDE PEDIATRIC GROUP, LLP
Entity type:Organization
Organization Name:EASTSIDE PEDIATRIC GROUP, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ELEANOR
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-656-8750
Mailing Address - Street 1:5900 N BURDICK ST
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9462
Mailing Address - Country:US
Mailing Address - Phone:315-656-8750
Mailing Address - Fax:315-656-8493
Practice Address - Street 1:5900 N BURDICK ST
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9462
Practice Address - Country:US
Practice Address - Phone:315-656-8750
Practice Address - Fax:315-656-8493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01397373Medicaid