Provider Demographics
NPI:1134308851
Name:NORTHSIDE FAMILY MEDICINE, P.S.
Entity Type:Organization
Organization Name:NORTHSIDE FAMILY MEDICINE, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:HH
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-489-9700
Mailing Address - Street 1:220 E ROWAN AVE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-1202
Mailing Address - Country:US
Mailing Address - Phone:509-489-9700
Mailing Address - Fax:509-489-9800
Practice Address - Street 1:220 E ROWAN AVE
Practice Address - Street 2:SUITE 330
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-1202
Practice Address - Country:US
Practice Address - Phone:509-489-9700
Practice Address - Fax:509-489-9800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037404173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB32919Medicare PIN