Provider Demographics
NPI:1659458776
Name:NORTHLAKE MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:NORTHLAKE MEDICAL CENTER, LLC
Other - Org Name:NORTHLAKE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-270-3010
Mailing Address - Street 1:1455 MONTREAL RD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-8100
Mailing Address - Country:US
Mailing Address - Phone:770-270-3000
Mailing Address - Fax:770-270-3199
Practice Address - Street 1:1455 MONTREAL RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-8100
Practice Address - Country:US
Practice Address - Phone:770-270-3000
Practice Address - Fax:770-270-3199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC11105BMedicaid