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General NPI Number Information
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NPI Number | 1811424245
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Entity Type | Organization
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Legal Business Name | EASTSIDE CARDIOVASCULAR MEDICINE
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Dates
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Enumeration Date | 05/16/2017
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Last Update Date | 05/16/2017
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Provider Practice Location Address
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Address Line | 25195 KELLY RD STE A
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City | ROSEVILLE
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State | MI
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Zip | 48066-4909
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Country | US
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Telephone | 586-775-4594
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Fax | 586-775-4506
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Provider Business Mailing Address
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Address Line | 25195 KELLY RD STE A
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City | ROSEVILLE
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State | MI
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Zip | 48066-4909
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Country | US
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Telephone | 586-775-4594
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Fax | 586-775-4506
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. VAMSHIDHAR GUDUGUNTLA
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Credential | MD
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Telephone | 313-461-8684
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RI0011X
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Taxonomy Name | Interventional Cardiology Physician
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License Number | 4301094061
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License Number State | MI
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