Healthcare Provider Details

I. General information

NPI: 1013960657
Provider Name (Legal Business Name): NORTHSIDE RADIOLOGY ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JOHNSON FERRY RD
ATLANTA GA
30342-1606
US

IV. Provider business mailing address

PO BOX 102263
ATLANTA GA
30368-2263
US

V. Phone/Fax

Practice location:
  • Phone: 678-553-7784
  • Fax: 678-553-7793
Mailing address:
  • Phone: 678-553-7784
  • Fax: 678-553-7794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: SHARLEE LEBLEU
Title or Position: VICE PRESIDENT
Credential:
Phone: 480-321-7026