MEDICARE: NORTHSIDE HOSPITAL, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PHRE007668	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2018667	OTHER		PK

General Provider Information

NPI Number	:	1679572861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE HOSPITAL, INC.

Provider Business Mailing Address
First Line	:	3400 OLD MILTON PKWY # A
Second Line	:	SUITE 140
City	:	ALPHARETTA
State	:	GA
Zip	:	30005-3707
Country	:	US
Telephone Number	:	770-667-4023
Fax Number	:	770-751-7292

Provider Business Practice Location Address
First Line	:	3400 OLD MILTON PKWY # A
Second Line	:	SUITE 140
City	:	ALPHARETTA
State	:	GA
Zip	:	30005-3707
Country	:	US
Telephone Number	:	770-667-4023
Fax Number	:	770-751-7292

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JUDY GARDNER
Credential	:
Telephone Number	:	404-851-6793

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	06/17/2016

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Directions to “NORTHSIDE HOSPITAL, INC. ” Practice Location

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