Provider Demographics
NPI:1205103231
Name:NORTHSIDE FAMILY PRACTICE PLLC
Entity type:Organization
Organization Name:NORTHSIDE FAMILY PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PRAKASH
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-704-9408
Mailing Address - Street 1:3606 N MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74106-6447
Mailing Address - Country:US
Mailing Address - Phone:918-794-3536
Mailing Address - Fax:918-794-7784
Practice Address - Street 1:3606 N MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-6447
Practice Address - Country:US
Practice Address - Phone:918-794-3536
Practice Address - Fax:918-794-7784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-18
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty