Provider Demographics
NPI:1245226398
Name:NORTHSIDE MEDICAL CLINIC WALK IN LLC
Entity type:Organization
Organization Name:NORTHSIDE MEDICAL CLINIC WALK IN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:928-539-0055
Mailing Address - Street 1:1394 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-4430
Mailing Address - Country:US
Mailing Address - Phone:928-539-0055
Mailing Address - Fax:928-539-0053
Practice Address - Street 1:1394 W 16TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-4430
Practice Address - Country:US
Practice Address - Phone:928-539-0055
Practice Address - Fax:928-539-0053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC3723261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========OtherNORTHSIDE TAX ID
AZ102892Medicare ID - Type UnspecifiedWALLSTROM MEDICARE
AZH05396Medicare UPIN
AZ102893Medicare ID - Type UnspecifiedORTIZ MEDICARE
AZ=========OtherNORTHSIDE TAX ID
AZAZ102887Medicare ID - Type UnspecifiedNORTHSIDE MEDICARE