Provider Demographics
NPI:1649353657
Name:NORTHSIDE OB/GYN INC
Entity type:Organization
Organization Name:NORTHSIDE OB/GYN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN SECRETARY & TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:AUSTIN
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-872-8660
Mailing Address - Street 1:8330 NAAB RD
Mailing Address - Street 2:SUITE # 103
Mailing Address - City:INDPLS
Mailing Address - State:IN
Mailing Address - Zip Code:46260
Mailing Address - Country:US
Mailing Address - Phone:317-872-8660
Mailing Address - Fax:317-872-6524
Practice Address - Street 1:8330 NAAB RD
Practice Address - Street 2:SUITE # 103
Practice Address - City:INDPLS
Practice Address - State:IN
Practice Address - Zip Code:46260
Practice Address - Country:US
Practice Address - Phone:317-872-8660
Practice Address - Fax:317-872-6524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022825207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10036223OAMedicaid
000000083369OtherANTHEM
065770BMedicare ID - Type Unspecified
E15096Medicare UPIN