Provider Demographics
NPI:1962872218
Name:EASTSIDE SURGICAL ASSISTANTS LLC
Entity type:Organization
Organization Name:EASTSIDE SURGICAL ASSISTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED SURGICAL ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-799-2498
Mailing Address - Street 1:925 MAIN ST
Mailing Address - Street 2:SUITE 300-07
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3098
Mailing Address - Country:US
Mailing Address - Phone:678-799-2498
Mailing Address - Fax:
Practice Address - Street 1:925 MAIN ST
Practice Address - Street 2:SUITE 300-07
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3098
Practice Address - Country:US
Practice Address - Phone:678-799-2498
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty