Provider Demographics
NPI:1396945515
Name:NORTHSIDE CHILDREN'S PEDIATRIC CENTER, LLC
Entity type:Organization
Organization Name:NORTHSIDE CHILDREN'S PEDIATRIC CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RN-PNP, MEMBER, AND (SPOUSE OF MD)
Authorized Official - Prefix:PROF
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:HEATON
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, PNP, RNC
Authorized Official - Phone:770-720-6963
Mailing Address - Street 1:391 EAST MAIN STREET
Mailing Address - Street 2:HISTORIC HAWKINS BUILDING
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2712
Mailing Address - Country:US
Mailing Address - Phone:770-720-6963
Mailing Address - Fax:770-720-6965
Practice Address - Street 1:391 EAST MAIN STREET
Practice Address - Street 2:HISTORIC HAWKINS BUILDING
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2712
Practice Address - Country:US
Practice Address - Phone:770-720-6963
Practice Address - Fax:770-720-6965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA PHYSICIAN 54532261QP2300X
GAGA 54532208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA629697125AMedicaid
GA1396945515OtherAUTH REPRESENTATIVE: MICHAEL G. ANDERSON, MD, ENTITY ATTENDING PHYSICIAN