Provider Demographics
NPI:1720096852
Name:NORTHSIDE FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:NORTHSIDE FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROYSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:505-823-1805
Mailing Address - Street 1:6100 PAN AMERICAN FREEWAY, NE
Mailing Address - Street 2:SUITE 390
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3401
Mailing Address - Country:US
Mailing Address - Phone:505-823-1805
Mailing Address - Fax:505-823-1844
Practice Address - Street 1:6100 PAN AMERICAN FREEWAY, NE
Practice Address - Street 2:SUITE 390
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3401
Practice Address - Country:US
Practice Address - Phone:505-823-1805
Practice Address - Fax:505-823-1844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA91890207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMF8984Medicaid
NMF8984Medicaid
F40225Medicare UPIN