Provider Demographics
NPI:1801910229
Name:EAST SIDE FOOT & ANKLE CLINIC PC
Entity type:Organization
Organization Name:EAST SIDE FOOT & ANKLE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:586-776-7000
Mailing Address - Street 1:22301 GREATER MACK AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2376
Mailing Address - Country:US
Mailing Address - Phone:586-776-7000
Mailing Address - Fax:586-776-7003
Practice Address - Street 1:22301 GREATER MACK AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2376
Practice Address - Country:US
Practice Address - Phone:586-776-7000
Practice Address - Fax:586-776-7003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001005332BC3200X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2926711Medicaid
MI89594BOtherHAP
MI480014028OtherRAILROAD MEDICARE PTAN
MI0005335144OtherAETNA
MI0Q24605OtherBLUECROSS PIN
MI0Q24605Medicare PIN
MI3966010001Medicare NSC
MI0Q24605OtherBLUECROSS PIN