Provider Demographics
NPI:1659344133
Name:NORTHSIDE GASTROENTEROLOGY ENDOSCOPY CENTER LLC
Entity Type:Organization
Organization Name:NORTHSIDE GASTROENTEROLOGY ENDOSCOPY CENTER LLC
Other - Org Name:NORTHSIDE GASTROENTEROLOGY ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1A BURTON HILLS BLVD
Mailing Address - Street 2:ATTN: L&C
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6103
Mailing Address - Country:US
Mailing Address - Phone:317-871-7308
Mailing Address - Fax:317-871-7314
Practice Address - Street 1:8424 NAAB RD
Practice Address - Street 2:SUITE 3-G
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-5918
Practice Address - Country:US
Practice Address - Phone:317-871-7308
Practice Address - Fax:317-871-7314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05-008902261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN490003884OtherRAILROAD MEDICARE
IN200119350AMedicaid
IN200119350AMedicaid
IN490003884OtherRAILROAD MEDICARE