Provider Demographics
NPI:1679917835
Name:COMPREHENSIVE INTERNAL MEDICINE AT NORTHSIDE
Entity Type:Organization
Organization Name:COMPREHENSIVE INTERNAL MEDICINE AT NORTHSIDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:T
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MS
Authorized Official - Phone:678-205-9004
Mailing Address - Street 1:11975 MORRIS RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4419
Mailing Address - Country:US
Mailing Address - Phone:678-205-9004
Mailing Address - Fax:678-205-9005
Practice Address - Street 1:960 JOHNSON FERRY RD NE
Practice Address - Street 2:SUITE 543
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1631
Practice Address - Country:US
Practice Address - Phone:678-205-9004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-18
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG90438Medicare UPIN
GAH00715Medicare UPIN
GAH73794Medicare UPIN