Basic Information
| Provider Information | |||||||||
| NPI: | 1215095930 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTSIDE MEDICAL OFFICE , PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3117 41ST ST | ||||||||
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| City: | ASTORIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111033901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182785100 | ||||||||
| FaxNumber: | 7182786757 | ||||||||
| Practice Location | |||||||||
| Address1: | 58 E 116TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100291147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128769700 | ||||||||
| FaxNumber: | 2128765745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 10/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | OO | ||||||||
| AuthorizedOfficialFirstName: | ZAW | ||||||||
| AuthorizedOfficialMiddleName: | MIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2128769700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 136246 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RG0100X | 176228 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RN0300X | 205570 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 2084P0800X | 230776 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 207N00000X | 214914 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207R00000X | 198749 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01369795 | 05 | NY | MEDICAID | 01843681 | 05 | NY | MEDICAID | 02678706 | 05 | NY | MEDICAID | 02232575 | 05 | NY | MEDICAID | 01616673 | 05 | NY | MEDICAID |