1740355338 NPI number — NORTHSIDE SURGICAL ASSOCIATE

Table of content: (NPI 1740355338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740355338 NPI number — NORTHSIDE SURGICAL ASSOCIATE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHSIDE SURGICAL ASSOCIATE
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:
1740355338
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
80 INTERSTATE SOUTH DR
Provider Second Line Business Mailing Address:
STE B
Provider Business Mailing Address City Name:
JASPER
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30143-6226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-692-9081
Provider Business Mailing Address Fax Number:
706-692-0155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 INTERSTATE SOUTH DR
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
JASPER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30143-6226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-692-9081
Provider Business Practice Location Address Fax Number:
706-692-0155
Provider Enumeration Date:
11/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LANGELLA
Authorized Official First Name:
ROSA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CO OWNER
Authorized Official Telephone Number:
706-692-9081

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , 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: H9749 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 300021256A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com