Provider Demographics
NPI:1356300073
Name:NORTHSIDE PEDIATRICS PC
Entity Type:Organization
Organization Name:NORTHSIDE PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:ANSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-962-6221
Mailing Address - Street 1:265 FREMONT ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-3354
Mailing Address - Country:US
Mailing Address - Phone:269-962-6223
Mailing Address - Fax:269-962-9309
Practice Address - Street 1:265 FREMONT ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3354
Practice Address - Country:US
Practice Address - Phone:269-962-6223
Practice Address - Fax:269-962-9309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX ID