Provider Demographics
NPI:1578583167
Name:NORTHSIDE NEPHROLOGY,P.C.
Entity Type:Organization
Organization Name:NORTHSIDE NEPHROLOGY,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DWARAKINATH
Authorized Official - Middle Name:
Authorized Official - Last Name:HARISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-455-7748
Mailing Address - Street 1:1445 HAW CREEK CIR
Mailing Address - Street 2:504
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-6569
Mailing Address - Country:US
Mailing Address - Phone:678-455-7748
Mailing Address - Fax:678-455-7751
Practice Address - Street 1:1445 HAW CREEK CIR
Practice Address - Street 2:504
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6569
Practice Address - Country:US
Practice Address - Phone:678-455-7748
Practice Address - Fax:678-455-7751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051229207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00959406EMedicaid
GAGRP6401Medicare PIN
GA00959406EMedicaid