Provider Demographics
NPI:1891836342
Name:NORTHSIDE BARIATRIC SURGERY CENTER
Entity Type:Organization
Organization Name:NORTHSIDE BARIATRIC SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TIFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSTWICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-252-2220
Mailing Address - Street 1:960 JOHNSON FERRY RD NE
Mailing Address - Street 2:SUITE 228
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1631
Mailing Address - Country:US
Mailing Address - Phone:404-252-2220
Mailing Address - Fax:404-252-4530
Practice Address - Street 1:960 JOHNSON FERRY RD NE
Practice Address - Street 2:SUITE 228
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1631
Practice Address - Country:US
Practice Address - Phone:404-252-2220
Practice Address - Fax:404-252-4530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA37604208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty