Provider Demographics
NPI:1811184245
Name:EASTSIDE ENDOCRINE, PC
Entity type:Organization
Organization Name:EASTSIDE ENDOCRINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NALAND
Authorized Official - Middle Name:P
Authorized Official - Last Name:SHENOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-979-7466
Mailing Address - Street 1:1600 MEDICAL WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078
Mailing Address - Country:US
Mailing Address - Phone:770-979-7466
Mailing Address - Fax:770-979-7455
Practice Address - Street 1:1600 MEDICAL WAY
Practice Address - Street 2:SUITE200
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078
Practice Address - Country:US
Practice Address - Phone:770-979-7466
Practice Address - Fax:770-979-7455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053165207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP5151OtherMEDICARE GROUP