Provider Demographics
NPI:1750530473
Name:EASTGATE INTERNAL MEDICINE LTD
Entity type:Organization
Organization Name:EASTGATE INTERNAL MEDICINE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JABEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-925-8842
Mailing Address - Street 1:8734 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-1617
Mailing Address - Country:US
Mailing Address - Phone:269-925-8842
Mailing Address - Fax:269-925-8847
Practice Address - Street 1:1686 COLFAX AVE
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-7355
Practice Address - Country:US
Practice Address - Phone:269-925-8842
Practice Address - Fax:269-925-8847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064652261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1073694006OtherNPI NUMBER-TYPE I
MI4301064652OtherMICHIGAN MEDICAL LICENSE NUMBER
MI1101111252OtherBLUECROSS BLUESHIELD OF MICHIGAN
MI415194310Medicaid
MI415194310Medicaid
MI0N19400Medicare PIN