1063434272 NPI number — NORTHSIDE RADIATION ONCOLOGY PC

Table of content: (NPI 1063434272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063434272 NPI number — NORTHSIDE RADIATION ONCOLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHSIDE RADIATION ONCOLOGY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THOMAS W. PHILLIPS, M.D., P.C.
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063434272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 932154
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31193-2154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-851-8850
Provider Business Mailing Address Fax Number:
404-851-6010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 JOHNSON FERRY RD NE
Provider Second Line Business Practice Location Address:
NORTHSIDE HOSPITAL CANCER CENTER
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30342-1606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-851-8850
Provider Business Practice Location Address Fax Number:
404-851-6010
Provider Enumeration Date:
07/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PHILLIPS
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
404-851-8850

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  0012112 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00144559H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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