Provider Demographics
NPI:1740245950
Name:NORTHSIDE PLASTIC SURGERY
Entity Type:Organization
Organization Name:NORTHSIDE PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPING INSURANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:REINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-751-1433
Mailing Address - Street 1:1265 UPPER HEMBREE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1143
Mailing Address - Country:US
Mailing Address - Phone:770-751-1433
Mailing Address - Fax:770-751-7410
Practice Address - Street 1:1265 UPPER HEMBREE RD
Practice Address - Street 2:STE 100
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1143
Practice Address - Country:US
Practice Address - Phone:770-751-1433
Practice Address - Fax:770-751-7410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP863Medicare ID - Type Unspecified