Healthcare Provider Details

I. General information

NPI: 1427112259
Provider Name (Legal Business Name): EASTSIDE INTERNAL MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 10/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 GUNBARREL ROAD SUITE 206
CHATTANOOGA TN
37421
US

IV. Provider business mailing address

PO BOX 21090
CHATTANOOGA TN
37424-0090
US

V. Phone/Fax

Practice location:
  • Phone: 423-648-8110
  • Fax: 423-443-4297
Mailing address:
  • Phone: 423-648-8110
  • Fax: 423-443-4297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number31560
License Number StateTN

VIII. Authorized Official

Name: ROGER ALAY
Title or Position: OFFICE MANAGER
Credential:
Phone: 423-648-8110