=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861493199
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTSIDE CARDIOVASCULAR MEDICINE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2005
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25195 KELLY ROAD SUITE A
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48066-4909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-775-4594
-----------------------------------------------------
Fax | 586-775-4506
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25195 KELLY RD SUITE A
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48066-4909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-775-4594
-----------------------------------------------------
Fax | 586-775-4506
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/EASTSIDE CARDIOVASCULAR M
-----------------------------------------------------
Name | VAMSHIDHAR D GUDUGUNTIA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 586-775-4594
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------