Provider Demographics
NPI:1861527863
Name:EAST SIDE FAMILY PRACTICE SC
Entity type:Organization
Organization Name:EAST SIDE FAMILY PRACTICE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:DOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:920-437-4366
Mailing Address - Street 1:424 S MONROE AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4054
Mailing Address - Country:US
Mailing Address - Phone:920-437-4366
Mailing Address - Fax:920-437-0954
Practice Address - Street 1:424 S MONROE AVE STE 106
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4054
Practice Address - Country:US
Practice Address - Phone:920-437-4366
Practice Address - Fax:920-437-0954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26550208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
80085001OtherRR MEDICARE PROV #
WI30021900Medicaid
80085001OtherRR MEDICARE PROV #
B52453Medicare UPIN