Provider Demographics
NPI:1851515597
Name:NORTHSIDE PEDIATRIC ASSOCIATES, PC
Entity Type:Organization
Organization Name:NORTHSIDE PEDIATRIC ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOWNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-379-9524
Mailing Address - Street 1:4225 VICKERS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-4649
Mailing Address - Country:US
Mailing Address - Phone:812-379-9524
Mailing Address - Fax:812-376-6383
Practice Address - Street 1:4225 VICKERS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-4649
Practice Address - Country:US
Practice Address - Phone:812-379-9524
Practice Address - Fax:812-376-6383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038736208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10083360AMedicaid