1396945515 NPI number — NORTHSIDE CHILDREN'S PEDIATRIC CENTER, LLC

Table of content: (NPI 1396945515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396945515 NPI number — NORTHSIDE CHILDREN'S PEDIATRIC CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHSIDE CHILDREN'S PEDIATRIC CENTER, LLC
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:
NORTHSIDE CHILDREN'S PEDIATRICS CENTER, PC
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:
1396945515
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
391 EAST MAIN STREET
Provider Second Line Business Mailing Address:
HISTORIC HAWKINS BUILDING
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30114-2712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-720-6963
Provider Business Mailing Address Fax Number:
770-720-6965

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
391 EAST MAIN STREET
Provider Second Line Business Practice Location Address:
HISTORIC HAWKINS BUILDING
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30114-2712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-720-6963
Provider Business Practice Location Address Fax Number:
770-720-6965
Provider Enumeration Date:
07/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
HEATON
Authorized Official Title or Position:
RN-PNP, MEMBER, AND (SPOUSE OF MD)
Authorized Official Telephone Number:
770-720-6963

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  GA 54532 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2300X , with the licence number: GA PHYSICIAN 54532 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 629697125A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396945515 . This is a "AUTH REPRESENTATIVE: MICHAEL G. ANDERSON, MD, ENTITY ATTENDING PHYSICIAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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