MEDICARE: EAST SIDE IMAGING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	293D00000X	Physiological Laboratory

General Provider Information

NPI Number	:	1316425432
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST SIDE IMAGING, LLC

Provider Business Mailing Address
First Line	:	PO BOX 645846
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45264-5846
Country	:	US
Telephone Number	:	866-674-7933
Fax Number	:	952-513-6880

Provider Business Practice Location Address
First Line	:	3702 S STATE ST STE 111
Second Line	:
City	:	SOUTH SALT LAKE
State	:	UT
Zip	:	84115-5078
Country	:	US
Telephone Number	:	801-288-9671
Fax Number	:	801-288-9583

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	ALBERT C. VAN KIRK
Credential	:
Telephone Number	:	330-653-3968

Provider Enumeration Date	:	07/31/2018
Last Update Date	:	08/11/2021

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