Provider Demographics
NPI:1831201821
Name:EASTSIDE INTERNAL MEDICINE PC
Entity type:Organization
Organization Name:EASTSIDE INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:ECKENWILER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-552-1710
Mailing Address - Street 1:28315 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1687
Mailing Address - Country:US
Mailing Address - Phone:586-552-1710
Mailing Address - Fax:586-552-1715
Practice Address - Street 1:28315 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1687
Practice Address - Country:US
Practice Address - Phone:586-552-1710
Practice Address - Fax:586-552-1715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301049083207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N51910Medicare PIN