Basic Information
| Provider Information | |||||||||
| NPI: | 1467406132 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EASTSIDE MEDICAL CENTER, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | PIEDMONT EASTSIDE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 MEDICAL WAY | ||||||||
| Address2: | |||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300782195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709790200 | ||||||||
| FaxNumber: | 7707362395 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 MEDICAL WAY | ||||||||
| Address2: | |||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300782195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709790200 | ||||||||
| FaxNumber: | 7707362395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CROSS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | VP GOVERNMENT REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 4702713401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 119513 | 05 | AZ | MEDICAID | 1526531 | 01 | GATEWAY MEDICAID HMO | OTHER | 421810000 | 05 | ME | MEDICAID | 071850401 | 05 | TX | MEDICAID | 30000595 | 05 | PA | MEDICAID | 200225640A | 05 | IN | MEDICAID | 3564 | 01 | BLUE CROSS | OTHER | 909638800 | 05 | FL | MEDICAID | HOS0192N | 05 | AL | MEDICAID | 0110192 | 05 | TN | MEDICAID | 50002177 | 05 | KY | MEDICAID | 82092 | 05 | NY | MEDICAID | XHSP33294 | 05 | CA | MEDICAID | 1010484 | 05 | MA | MEDICAID | 00190088A | 05 | GA | MEDICAID | 036540100 | 05 | DC | MEDICAID | 157505105 | 05 | AR | MEDICAID | 158328200 | 01 | DEPT OF LABOR | OTHER | 4001267 | 01 | BLUE CARE | OTHER | 3022050 | 05 | WA | MEDICAID | 308068059 | 05 | MI | MEDICAID | 406635900 | 05 | MD | MEDICAID | 0067598 | 05 | NJ | MEDICAID | 143405 | 05 | SC | MEDICAID | 1633343 | 05 | NY | MEDICAID | 82176800 | 05 | WI | MEDICAID |