Provider Demographics
NPI:1568578201
Name:NORTHSIDE GASTROENTEROLOGY, INC., PC
Entity Type:Organization
Organization Name:NORTHSIDE GASTROENTEROLOGY, INC., PC
Other - Org Name:NORTHSIDE GASTROENTEROLOGY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:GALINTON
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-872-7396
Mailing Address - Street 1:8424 NAAB RD
Mailing Address - Street 2:SUITE 3-J
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5918
Mailing Address - Country:US
Mailing Address - Phone:317-872-7396
Mailing Address - Fax:317-879-8328
Practice Address - Street 1:8424 NAAB RD
Practice Address - Street 2:SUITE 3-J
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260
Practice Address - Country:US
Practice Address - Phone:317-872-7396
Practice Address - Fax:317-879-8328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100177420Medicaid