Provider Demographics
NPI:1518366178
Name:AFFILIATED
Entity Type:Organization
Organization Name:AFFILIATED
Other - Org Name:NORTHSIDE MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-295-3838
Mailing Address - Street 1:3138 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-8028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5900 COLLEGE RD
Practice Address - Street 2:EKG-DEPT.
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-4342
Practice Address - Country:US
Practice Address - Phone:305-295-3838
Practice Address - Fax:305-295-7772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0066579207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty