Healthcare Provider Details

I. General information

NPI: 1396945515
Provider Name (Legal Business Name): NORTHSIDE CHILDREN'S PEDIATRIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

391 EAST MAIN STREET HISTORIC HAWKINS BUILDING
CANTON GA
30114-2712
US

IV. Provider business mailing address

391 EAST MAIN STREET HISTORIC HAWKINS BUILDING
CANTON GA
30114-2712
US

V. Phone/Fax

Practice location:
  • Phone: 770-720-6963
  • Fax: 770-720-6965
Mailing address:
  • Phone: 770-720-6963
  • Fax: 770-720-6965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberGA 54532
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberGA PHYSICIAN 54532
License Number StateGA

VIII. Authorized Official

Name: PROF. STEPHANIE HEATON ANDERSON
Title or Position: RN-PNP, MEMBER, AND (SPOUSE OF MD)
Credential: DNP, PNP, RNC
Phone: 770-720-6963