Provider Demographics
NPI:1902848286
Name:NORTHSIDE FOOT & ANKLE OUTPATIENT SURGICAL CENTER, INC
Entity Type:Organization
Organization Name:NORTHSIDE FOOT & ANKLE OUTPATIENT SURGICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SURGICAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:PORTIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-384-0284
Mailing Address - Street 1:3415 HOLCOMB BRIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-3102
Mailing Address - Country:US
Mailing Address - Phone:770-580-2424
Mailing Address - Fax:770-580-2425
Practice Address - Street 1:3415 HOLCOMB BRIDGE ROAD
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-3102
Practice Address - Country:US
Practice Address - Phone:770-580-2424
Practice Address - Fax:770-580-2425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA1903X
GA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111051ASCAMedicare PIN