Healthcare Provider Details

I. General information

NPI: 1619925070
Provider Name (Legal Business Name): EASTSIDE P.E.T. CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 MEDICAL PARK DR E STE 224
BIRMINGHAM AL
35235-3401
US

IV. Provider business mailing address

406 MEDICAL CENTER DR
JASPER AL
35501-3400
US

V. Phone/Fax

Practice location:
  • Phone: 205-838-3738
  • Fax: 205-838-6738
Mailing address:
  • Phone: 205-221-8200
  • Fax: 205-221-8270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA J. WELLS
Title or Position: VICE-PRESIDENT
Credential: CPCO
Phone: 205-221-8258