Healthcare Provider Details

I. General information

NPI: 1487653283
Provider Name (Legal Business Name): NORTHSIDE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 NORTHSIDE FORSYTH DR
CUMMING GA
30041-7659
US

IV. Provider business mailing address

1200 NORTHSIDE FORSYTH DR
CUMMING GA
30041-7659
US

V. Phone/Fax

Practice location:
  • Phone: 770-844-3396
  • Fax: 770-844-3397
Mailing address:
  • Phone: 770-844-3396
  • Fax: 770-844-3397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHRE007472
License Number StateGA

VIII. Authorized Official

Name: MRS. RAE LYNN BENTON
Title or Position: DIRECTOR OF PHARMACY
Credential: RPH
Phone: 770-844-3291