Healthcare Provider Details

I. General information

NPI: 1568578201
Provider Name (Legal Business Name): NORTHSIDE GASTROENTEROLOGY, INC., PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8424 NAAB RD SUITE 3-J
INDIANAPOLIS IN
46260
US

IV. Provider business mailing address

8424 NAAB RD SUITE 3-J
INDIANAPOLIS IN
46260-5918
US

V. Phone/Fax

Practice location:
  • Phone: 317-872-7396
  • Fax: 317-879-8328
Mailing address:
  • Phone: 317-872-7396
  • Fax: 317-879-8328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: GALINTON BRYAN
Title or Position: PRACTICE ADMIN
Credential:
Phone: 317-872-7396