Provider Demographics
NPI:1962946970
Name:EASTSIDE FAMILY MEDICINE
Entity type:Organization
Organization Name:EASTSIDE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SEBRINA
Authorized Official - Middle Name:B
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-216-9648
Mailing Address - Street 1:22289 MEDICAL VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35613-2896
Mailing Address - Country:US
Mailing Address - Phone:256-232-1414
Mailing Address - Fax:
Practice Address - Street 1:22289 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35613-2896
Practice Address - Country:US
Practice Address - Phone:256-232-1414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-09
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty