Basic Information
| Provider Information | |||||||||
| NPI: | 1831290915 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTSIDE PATHOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1457 | ||||||||
| Address2: | |||||||||
| City: | BLUEFIELD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247011457 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 MEDICAL WAY | ||||||||
| Address2: | PATHOLOGY DEPT | ||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709790200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 09/29/2009 | ||||||||
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| AuthorizedOfficialLastName: | NUNNERY | ||||||||
| AuthorizedOfficialFirstName: | EDWIN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7709790200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 300033615A | 05 | GA | MEDICAID | CN5006 | 01 | RAILROAD MEDICARE | OTHER |