Provider Demographics
NPI:1427112259
Name:EASTSIDE INTERNAL MEDICINE PC
Entity type:Organization
Organization Name:EASTSIDE INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:ALAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-648-8110
Mailing Address - Street 1:PO BOX 21090
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37424-0090
Mailing Address - Country:US
Mailing Address - Phone:423-648-8110
Mailing Address - Fax:423-443-4297
Practice Address - Street 1:1720 GUNBARREL ROAD
Practice Address - Street 2:SUITE 206
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421
Practice Address - Country:US
Practice Address - Phone:423-648-8110
Practice Address - Fax:423-443-4297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31560261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3888401Medicaid
G99682Medicare UPIN
TN3888401Medicaid