Healthcare Provider Details

I. General information

NPI: 1659081461
Provider Name (Legal Business Name): EAST SIDE INTEGRATIVE MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARKER AVE STE 200
WHITE PLAINS NY
10601-1523
US

IV. Provider business mailing address

1 BARKER AVE STE 200
WHITE PLAINS NY
10601-1523
US

V. Phone/Fax

Practice location:
  • Phone: 845-422-6504
  • Fax:
Mailing address:
  • Phone: 845-422-6504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN JAMES MEDRANO
Title or Position: DIRECTOR
Credential:
Phone: 720-251-9215