Healthcare Provider Details

I. General information

NPI: 1679572861
Provider Name (Legal Business Name): NORTHSIDE HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 OLD MILTON PKWY # A SUITE 140
ALPHARETTA GA
30005-3707
US

IV. Provider business mailing address

3400 OLD MILTON PKWY # A SUITE 140
ALPHARETTA GA
30005-3707
US

V. Phone/Fax

Practice location:
  • Phone: 770-667-4023
  • Fax: 770-751-7292
Mailing address:
  • Phone: 770-667-4023
  • Fax: 770-751-7292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE007668
License Number StateGA

VIII. Authorized Official

Name: JUDY GARDNER
Title or Position: DIRECTOR
Credential:
Phone: 404-851-6793