Provider Demographics
NPI:1851454946
Name:NORTHSIDE,P.C.
Entity Type:Organization
Organization Name:NORTHSIDE,P.C.
Other - Org Name:NORTHSIDE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-675-4733
Mailing Address - Street 1:1020 CLEVELAND RD
Mailing Address - Street 2:
Mailing Address - City:SARALAND
Mailing Address - State:AL
Mailing Address - Zip Code:36571
Mailing Address - Country:US
Mailing Address - Phone:251-675-4733
Mailing Address - Fax:251-679-9874
Practice Address - Street 1:1020 CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:SARALAND
Practice Address - State:AL
Practice Address - Zip Code:36571
Practice Address - Country:US
Practice Address - Phone:251-675-4733
Practice Address - Fax:251-679-9874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529101630Medicaid
ALD946Medicare PIN
AL0863870001Medicare NSC