Provider Demographics
NPI:1396786042
Name:EASTSIDE OB/GYN P.L.L.C.
Entity type:Organization
Organization Name:EASTSIDE OB/GYN P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CODER
Authorized Official - Prefix:
Authorized Official - First Name:GLENNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ROE
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:479-484-5901
Mailing Address - Street 1:7001 ROGERS AVE
Mailing Address - Street 2:SUITE 502
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-4073
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7001 ROGERS AVE
Practice Address - Street 2:SUITE 502
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4073
Practice Address - Country:US
Practice Address - Phone:479-484-5901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR=========OtherTAX ID