Provider Demographics
NPI:1538286091
Name:NORTHSIDE CLINIC
Entity Type:Organization
Organization Name:NORTHSIDE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-233-1911
Mailing Address - Street 1:2211 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66104-5649
Mailing Address - Country:US
Mailing Address - Phone:913-233-1911
Mailing Address - Fax:913-321-5185
Practice Address - Street 1:2211 N 13TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66104-5649
Practice Address - Country:US
Practice Address - Phone:913-233-1911
Practice Address - Fax:913-321-5185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0428352207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSA79952Medicare UPIN
KSN01C033Medicare ID - Type Unspecified
KSN01C533Medicare ID - Type Unspecified
KSN010000Medicare ID - Type Unspecified