Provider Demographics
NPI:1265645063
Name:NORTHSIDE MEDICAL SPECIALISTS
Entity Type:Organization
Organization Name:NORTHSIDE MEDICAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SWAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-704-9499
Mailing Address - Street 1:145 RIVERSTONE TERRACE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5257
Mailing Address - Country:US
Mailing Address - Phone:770-704-9499
Mailing Address - Fax:770-704-9754
Practice Address - Street 1:145 RIVERSTONE TERRACE
Practice Address - Street 2:SUITE 100
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5257
Practice Address - Country:US
Practice Address - Phone:770-704-9499
Practice Address - Fax:770-704-9754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047083207R00000X
GA046761207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G21272Medicare UPIN
G13474Medicare UPIN
11BDVDBMedicare ID - Type Unspecified
10BBCLGMedicare ID - Type Unspecified