Healthcare Provider Details

I. General information

NPI: 1861493199
Provider Name (Legal Business Name): EASTSIDE CARDIOVASCULAR MEDICINE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25195 KELLY ROAD SUITE A
ROSEVILLE MI
48066-4909
US

IV. Provider business mailing address

25195 KELLY RD SUITE A
ROSEVILLE MI
48066-4909
US

V. Phone/Fax

Practice location:
  • Phone: 586-775-4594
  • Fax: 586-775-4506
Mailing address:
  • Phone: 586-775-4594
  • Fax: 586-775-4506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: VAMSHIDHAR D GUDUGUNTIA
Title or Position: PRESIDENT/EASTSIDE CARDIOVASCULAR M
Credential: M.D.
Phone: 586-775-4594