Healthcare Provider Details

I. General information

NPI: 1235365289
Provider Name (Legal Business Name): EASTSIDE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2009
Last Update Date: 06/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28963 LITTLE MACK AVE SUITE 103
SAINT CLAIR SHORES MI
48081-3017
US

IV. Provider business mailing address

28963 LITTLE MACK AVE SUITE 103
SAINT CLAIR SHORES MI
48081-3017
US

V. Phone/Fax

Practice location:
  • Phone: 586-447-5110
  • Fax:
Mailing address:
  • Phone: 586-447-5110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateMI

VIII. Authorized Official

Name: FERNANDO BERMUDEZ
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 586-447-5110