Provider Demographics
NPI:1295894137
Name:NORTHSIDE PEDIATRICS PSC
Entity type:Organization
Organization Name:NORTHSIDE PEDIATRICS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:DOTSON
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-678-5740
Mailing Address - Street 1:290 OLD JACKSON HWY 31E LOOP
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-9089
Mailing Address - Country:US
Mailing Address - Phone:270-678-5740
Mailing Address - Fax:
Practice Address - Street 1:290 OLD JACKSON HWY 31E LOOP
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-9089
Practice Address - Country:US
Practice Address - Phone:270-678-5740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19876208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000057724OtherBLUE CROSS BLUE SHIELD
KY64198765Medicaid
KYF26044Medicare UPIN