Provider Demographics
NPI:1013071273
Name:NORTHSIDE EAR, NOSE & THROAT, PC
Entity Type:Organization
Organization Name:NORTHSIDE EAR, NOSE & THROAT, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-475-3361
Mailing Address - Street 1:PO BOX 933087
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-3087
Mailing Address - Country:US
Mailing Address - Phone:770-475-3361
Mailing Address - Fax:770-664-4431
Practice Address - Street 1:1360 UPPER HEMBREE RD
Practice Address - Street 2:201
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1171
Practice Address - Country:US
Practice Address - Phone:770-475-3361
Practice Address - Fax:770-664-4431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059383207K00000X
GA036368207Y00000X
GA57545207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF52923Medicare UPIN