Provider Demographics
NPI:1811721442
Name:NORTHSIDE MEDICAL CLINIC
Entity type:Organization
Organization Name:NORTHSIDE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KLANCIE
Authorized Official - Middle Name:ALLISON
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:662-617-4894
Mailing Address - Street 1:1014A N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-2211
Mailing Address - Country:US
Mailing Address - Phone:662-617-4894
Mailing Address - Fax:662-384-5345
Practice Address - Street 1:1014A N JACKSON ST
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-2211
Practice Address - Country:US
Practice Address - Phone:662-617-4894
Practice Address - Fax:662-384-5345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center