Provider Demographics
NPI:1932218880
Name:EASTSIDE MEDICAL CONSULTANTS LLC
Entity Type:Organization
Organization Name:EASTSIDE MEDICAL CONSULTANTS LLC
Other - Org Name:MIJARES REINALDO
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REINALDO
Authorized Official - Middle Name:ERNESTO
Authorized Official - Last Name:MIJARES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-393-9933
Mailing Address - Street 1:105 S BROADWAY ST
Mailing Address - Street 2:SUITE 730
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-4227
Mailing Address - Country:US
Mailing Address - Phone:316-393-9933
Mailing Address - Fax:
Practice Address - Street 1:105 S BROADWAY ST
Practice Address - Street 2:SUITE 730
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-4227
Practice Address - Country:US
Practice Address - Phone:316-393-9933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS110680Medicare PIN