MEDICARE: EAST SIDE INTEGRATIVE MEDICINE PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0850X	Adult Mental Health Clinic/Center
2	261QM1300X	Multi-Specialty Clinic/Center
3	2084P0800X	Psychiatry Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	284877	OTHER	NY	PSYCHIATRIST

General Provider Information

NPI Number	:	1659081461
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST SIDE INTEGRATIVE MEDICINE PC

Provider Business Mailing Address
First Line	:	1 BARKER AVE STE 200
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10601-1523
Country	:	US
Telephone Number	:	845-422-6504
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 BARKER AVE STE 200
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10601-1523
Country	:	US
Telephone Number	:	845-422-6504
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	BENJAMIN JAMES MEDRANO
Credential	:
Telephone Number	:	720-251-9215

Provider Enumeration Date	:	12/02/2022
Last Update Date	:	02/05/2026

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