Provider Demographics
NPI:1205089372
Name:NORTHSIDE MEDICAL, INC.
Entity type:Organization
Organization Name:NORTHSIDE MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:THEAKSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-845-9355
Mailing Address - Street 1:PO BOX 680047
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35968-1601
Mailing Address - Country:US
Mailing Address - Phone:256-845-9355
Mailing Address - Fax:
Practice Address - Street 1:211 GREENHILL BLVD NW
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35967-3755
Practice Address - Country:US
Practice Address - Phone:256-845-9355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-02
Last Update Date:2008-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care