Provider Demographics
NPI:1700839826
Name:NORTHSIDE URGENT CARE, INC.
Entity Type:Organization
Organization Name:NORTHSIDE URGENT CARE, INC.
Other - Org Name:NORTHSIDE URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATION OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:Y
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-323-1481
Mailing Address - Street 1:5397 RAMSEY ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311
Mailing Address - Country:US
Mailing Address - Phone:910-488-9011
Mailing Address - Fax:910-488-6042
Practice Address - Street 1:5397 RAMSEY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311
Practice Address - Country:US
Practice Address - Phone:910-488-9011
Practice Address - Fax:910-488-9057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901011Medicaid
NC01011OtherBCBS GRP NUMBER
NC8901011Medicaid
NC8901011Medicaid