Provider Demographics
NPI:1083781595
Name:NORTHSIDE MEDICAL CLINIC, P.C.
Entity Type:Organization
Organization Name:NORTHSIDE MEDICAL CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BLENIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-668-2800
Mailing Address - Street 1:31 HUGHES DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-1505
Mailing Address - Country:US
Mailing Address - Phone:731-668-2800
Mailing Address - Fax:731-668-6161
Practice Address - Street 1:31 HUGHES DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-1505
Practice Address - Country:US
Practice Address - Phone:731-668-2800
Practice Address - Fax:731-668-6161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty