Healthcare Provider Details

I. General information

NPI: 1417077884
Provider Name (Legal Business Name): NORTHSIDE PEDIATRICS & ADOLESCENT MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 HAMMOND DRIVE SUITE E5250
ATLANTA GA
30328
US

IV. Provider business mailing address

333 SANDY SPRINGS CIRCLE SUITE 207
ATLANTA GA
30328-3834
US

V. Phone/Fax

Practice location:
  • Phone: 404-256-2688
  • Fax: 404-256-1820
Mailing address:
  • Phone: 404-705-8990
  • Fax: 404-705-9984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. VICKI M TITTLE
Title or Position: PRACTICE ADMINSTRATOR
Credential:
Phone: 404-705-8990