Provider Demographics
NPI:1922131770
Name:NORTHSIDE WOMENS CLINIC INC
Entity Type:Organization
Organization Name:NORTHSIDE WOMENS CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LORRI
Authorized Official - Middle Name:E
Authorized Official - Last Name:GAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-455-4210
Mailing Address - Street 1:3543 CHAMBLEE DUNWOODY ROAD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-2454
Mailing Address - Country:US
Mailing Address - Phone:770-455-4210
Mailing Address - Fax:770-451-9529
Practice Address - Street 1:3543 CHAMBLEE DUNWOODY ROAD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-2454
Practice Address - Country:US
Practice Address - Phone:770-455-4210
Practice Address - Fax:770-451-9529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044023261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical