Provider Demographics
NPI:1063564664
Name:EASTSIDE DERMATOLOGY, INC.
Entity type:Organization
Organization Name:EASTSIDE DERMATOLOGY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-863-3222
Mailing Address - Street 1:150 TAYLOR STATION RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213
Mailing Address - Country:US
Mailing Address - Phone:614-863-3222
Mailing Address - Fax:614-863-4450
Practice Address - Street 1:150 TAYLOR STATION RD
Practice Address - Street 2:SUITE 250
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213
Practice Address - Country:US
Practice Address - Phone:614-863-3222
Practice Address - Fax:614-863-4450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35054686207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000214662OtherSTEPHANIE COTELL ANTHEM I
OH1215972484OtherYAHNA T SMITH CNP NPI
OH1598751653OtherALAN PARKS NPI
OH000000118991OtherALAN PARKS ANTHEM ID
OH0665856Medicaid
OH1922093459OtherSTEPHANIE COTELL NPI
OH2285218Medicaid
OHC04059851Medicare ID - Type UnspecifiedSTEPHANIE COTELL MEDICARE
OH000000214662OtherSTEPHANIE COTELL ANTHEM I
OH9263901Medicare ID - Type UnspecifiedALAN PARKS MEDICARE
OH2285218Medicaid
OH0665856Medicaid