Provider Demographics
NPI:1083684112
Name:EASTSIDE INTERNAL MEDICINE-GERIATRICS, INC
Entity type:Organization
Organization Name:EASTSIDE INTERNAL MEDICINE-GERIATRICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JYOTI
Authorized Official - Middle Name:J
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-724-2226
Mailing Address - Street 1:PO BOX 643113
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45264-0307
Mailing Address - Country:US
Mailing Address - Phone:513-724-2226
Mailing Address - Fax:513-724-5248
Practice Address - Street 1:1001 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:OH
Practice Address - Zip Code:45176-1146
Practice Address - Country:US
Practice Address - Phone:513-724-2226
Practice Address - Fax:513-724-5248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDO8367OtherRR MCR
OH3007721Medicaid
OHDO8367OtherRR MCR