Provider Demographics
NPI:1215095930
Name:EASTSIDE MEDICAL OFFICE , PC
Entity type:Organization
Organization Name:EASTSIDE MEDICAL OFFICE , PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ZAW
Authorized Official - Middle Name:MIN
Authorized Official - Last Name:OO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-876-9700
Mailing Address - Street 1:3117 41ST ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-3901
Mailing Address - Country:US
Mailing Address - Phone:718-278-5100
Mailing Address - Fax:718-278-6757
Practice Address - Street 1:58 E 116TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-1147
Practice Address - Country:US
Practice Address - Phone:212-876-9700
Practice Address - Fax:212-876-5745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214914207N00000X
NY198749207R00000X
NY136246207RC0000X
NY176228207RG0100X
NY205570207RN0300X
NY2307762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01369795Medicaid
NY01843681Medicaid
NY02678706Medicaid
NY02232575Medicaid
NY01616673Medicaid
NY02678706Medicaid
NYI22971Medicare UPIN
NY11U793Medicare ID - Type Unspecified
NY01843681Medicaid
NY01369795Medicaid
NYH10012Medicare UPIN
NY467BY1Medicare ID - Type Unspecified
NY02232575Medicaid
NYG09904Medicare UPIN
NY42J041Medicare ID - Type Unspecified