Healthcare Provider Details

I. General information

NPI: 1588721435
Provider Name (Legal Business Name): NORTHSIDE GASTROENTEROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 JOHNSON FERRY RD NE SUITE 820
ATLANTA GA
30342-1626
US

IV. Provider business mailing address

980 JOHNSON FERRY RD NE SUITE 820
ATLANTA GA
30342-1626
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-9307
  • Fax: 404-252-5839
Mailing address:
  • Phone: 404-252-9307
  • Fax: 404-252-5839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number036306
License Number StateGA

VIII. Authorized Official

Name: DR. LORI J LUCAS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 404-252-9307