1679917835 NPI number — COMPREHENSIVE INTERNAL MEDICINE AT NORTHSIDE

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 1679917835 NPI number — COMPREHENSIVE INTERNAL MEDICINE AT NORTHSIDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPREHENSIVE INTERNAL MEDICINE AT NORTHSIDE
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:
1679917835
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11975 MORRIS RD
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
ALPHARETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30005-4419
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-205-9004
Provider Business Mailing Address Fax Number:
678-205-9005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
960 JOHNSON FERRY RD NE
Provider Second Line Business Practice Location Address:
SUITE 543
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30342-1631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-205-9004
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/18/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PEARSON
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
T
Authorized Official Title or Position:
MD OWNER
Authorized Official Telephone Number:
678-205-9004

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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