MEDICARE: EASTSIDE INTERNAL MEDICINE-GERIATRICS, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DO8367	OTHER	OH	RR MCR
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083684112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTSIDE INTERNAL MEDICINE-GERIATRICS, INC

Provider Business Mailing Address
First Line	:	PO BOX 643113
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45264-0307
Country	:	US
Telephone Number	:	513-724-2226
Fax Number	:	513-724-5248

Provider Business Practice Location Address
First Line	:	1001 W MAIN ST
Second Line	:
City	:	WILLIAMSBURG
State	:	OH
Zip	:	45176-1146
Country	:	US
Telephone Number	:	513-724-2226
Fax Number	:	513-724-5248

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JYOTI J MEHTA
Credential	:	MD
Telephone Number	:	513-724-2226

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	03/25/2010

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