Healthcare Provider Details

I. General information

NPI: 1356300073
Provider Name (Legal Business Name): NORTHSIDE PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 FREMONT ST SUITE 1
BATTLE CREEK MI
49017-3354
US

IV. Provider business mailing address

265 FREMONT ST SUITE 1
BATTLE CREEK MI
49017-3354
US

V. Phone/Fax

Practice location:
  • Phone: 269-962-6223
  • Fax: 269-962-9309
Mailing address:
  • Phone: 269-962-6223
  • Fax: 269-962-9309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: MRS. APRIL DIANE ANSELL
Title or Position: BILLING MANAGER
Credential:
Phone: 269-962-6221