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General NPI Number Information
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NPI Number | 1962872218
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Entity Type | Organization
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Legal Business Name | EASTSIDE SURGICAL ASSISTANTS LLC
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Dates
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Enumeration Date | 09/30/2015
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Last Update Date | 09/30/2015
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Provider Practice Location Address
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Address Line | 925 MAIN ST SUITE 300-07
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-3098
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Country | US
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Telephone | 678-799-2498
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Fax |
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Provider Business Mailing Address
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Address Line | 925 MAIN ST SUITE 300-07
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-3098
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Country | US
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Telephone | 678-799-2498
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Fax |
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Authorized Official
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Title or Position | CERTIFIED SURGICAL ASSISTANT
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Name | MR. SAMUEL FENDERSON
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Credential |
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Telephone | 678-799-2498
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number |
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License Number State |
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