1528253549 NPI number — NORTHSIDE DIGESTIVE DISEASES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528253549 NPI number — NORTHSIDE DIGESTIVE DISEASES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHSIDE DIGESTIVE DISEASES, INC.
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:
Provider Other Organization Name Type Code:
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:
1528253549
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4200 W MEMORIAL RD
Provider Second Line Business Mailing Address:
901
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73120-9350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-749-4247
Provider Business Mailing Address Fax Number:
405-749-4249

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 W MEMORIAL RD
Provider Second Line Business Practice Location Address:
901
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73120-9350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-749-4247
Provider Business Practice Location Address Fax Number:
405-749-4249
Provider Enumeration Date:
09/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KAKISH
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
RANDALL
Authorized Official Title or Position:
VIC PRESIDENT
Authorized Official Telephone Number:
405-749-4247

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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