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General NPI Number Information
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NPI Number | 1932256526
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Entity Type | Organization
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Legal Business Name | EASTSIDE INTERNAL MEDICINE, LLC
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Dates
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Enumeration Date | 01/04/2007
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 2080 EASTSIDE DR SUITE A
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City | CONYERS
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State | GA
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Zip | 30013-1953
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Country | US
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Telephone | 678-625-7800
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Fax | 678-625-7888
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Provider Business Mailing Address
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Address Line | 2080 EASTSIDE DR SUITE A
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City | CONYERS
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State | GA
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Zip | 30013-1953
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Country | US
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Telephone | 678-625-7800
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Fax | 678-625-7888
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | HENRIETTA MADDOX
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Credential |
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Telephone | 678-625-7800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 173000000X
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Taxonomy Name | Legal Medicine
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License Number |
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License Number State | GA
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