Provider Demographics
NPI:1215907845
Name:EASTSIDE ENT SPECIALISTS, INC
Entity type:Organization
Organization Name:EASTSIDE ENT SPECIALISTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:E.
Authorized Official - Middle Name:LUKE
Authorized Official - Last Name:BOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-352-1474
Mailing Address - Street 1:7580 AUBURN ROAD
Mailing Address - Street 2:#103
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077
Mailing Address - Country:US
Mailing Address - Phone:440-352-1474
Mailing Address - Fax:440-352-2662
Practice Address - Street 1:7580 AUBURN ROAD
Practice Address - Street 2:#103
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077
Practice Address - Country:US
Practice Address - Phone:440-352-1474
Practice Address - Fax:440-352-2662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0666364Medicaid
OH0666364Medicaid