Provider Demographics
NPI:1922308774
Name:EASTSIDE PRIMARY CARE LLC
Entity type:Organization
Organization Name:EASTSIDE PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:LENK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-946-4070
Mailing Address - Street 1:PO BOX 22958
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44122-0958
Mailing Address - Country:US
Mailing Address - Phone:216-595-9600
Mailing Address - Fax:216-595-9601
Practice Address - Street 1:36100 EUCLID AVE
Practice Address - Street 2:#430
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4456
Practice Address - Country:US
Practice Address - Phone:440-946-4070
Practice Address - Fax:440-946-4071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-27
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0819663Medicaid
OH0819663Medicaid
OH0688532Medicare PIN