Provider Demographics
NPI:1689743627
Name:FAMILY MEDICINE AT NORTHSIDE LLC
Entity Type:Organization
Organization Name:FAMILY MEDICINE AT NORTHSIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-762-5037
Mailing Address - Street 1:420 CHARTER BLVD
Mailing Address - Street 2:SUITE 3003
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4854
Mailing Address - Country:US
Mailing Address - Phone:478-475-4886
Mailing Address - Fax:478-475-4896
Practice Address - Street 1:420 CHARTER BLVD
Practice Address - Street 2:SUITE 3003
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4854
Practice Address - Country:US
Practice Address - Phone:478-475-4886
Practice Address - Fax:478-475-4896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTRICARE
GA=========OtherTRICARE
DF5207Medicare PIN