Healthcare Provider Details

I. General information

NPI: 1265645063
Provider Name (Legal Business Name): NORTHSIDE MEDICAL SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 RIVERSTONE TERRACE SUITE 100
CANTON GA
30114-5257
US

IV. Provider business mailing address

145 RIVERSTONE TERRACE SUITE 100
CANTON GA
30114-5257
US

V. Phone/Fax

Practice location:
  • Phone: 770-704-9499
  • Fax: 770-704-9754
Mailing address:
  • Phone: 770-704-9499
  • Fax: 770-704-9754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number047083
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number046761
License Number StateGA

VIII. Authorized Official

Name: CHRISTINA M SWAFFORD
Title or Position: OFFICE MANAGER
Credential:
Phone: 770-704-9499