Provider Demographics
NPI:1679572861
Name:NORTHSIDE HOSPITAL, INC.
Entity type:Organization
Organization Name:NORTHSIDE HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-851-6793
Mailing Address - Street 1:3400 OLD MILTON PKWY # A
Mailing Address - Street 2:SUITE 140
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-3707
Mailing Address - Country:US
Mailing Address - Phone:770-667-4023
Mailing Address - Fax:770-751-7292
Practice Address - Street 1:3400 OLD MILTON PKWY # A
Practice Address - Street 2:SUITE 140
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-3707
Practice Address - Country:US
Practice Address - Phone:770-667-4023
Practice Address - Fax:770-751-7292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0076683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2018667OtherPK