Provider Demographics
NPI:1124356324
Name:CITYSIDE HEALTHCARE
Entity Type:Organization
Organization Name:CITYSIDE HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:U
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-557-7186
Mailing Address - Street 1:950 DANNON VW SW
Mailing Address - Street 2:SUITE 4103
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-2160
Mailing Address - Country:US
Mailing Address - Phone:404-557-7186
Mailing Address - Fax:404-941-2657
Practice Address - Street 1:4502 PARKVIEW SQ
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-9408
Practice Address - Country:US
Practice Address - Phone:404-768-0440
Practice Address - Fax:404-768-0412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-27
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health