Provider Demographics
NPI:1295044097
Name:NORTHSIDE MEDICAL PROFESSIONALS, P.C.
Entity Type:Organization
Organization Name:NORTHSIDE MEDICAL PROFESSIONALS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:GENTRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-540-4210
Mailing Address - Street 1:1605 NASHVILLE HWY
Mailing Address - Street 2:STE. 200
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-2071
Mailing Address - Country:US
Mailing Address - Phone:931-540-4210
Mailing Address - Fax:931-380-1202
Practice Address - Street 1:1605 NASHVILLE HWY
Practice Address - Street 2:STE. 200
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-2071
Practice Address - Country:US
Practice Address - Phone:931-540-4210
Practice Address - Fax:931-380-1202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty