Healthcare Provider Details

I. General information

NPI: 1649393307
Provider Name (Legal Business Name): NORTHSIDE MEDICAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

978 ROUTE 45 SUITE 109A
POMONA NY
10970-3521
US

IV. Provider business mailing address

131 CRAIG RD
HILLSDALE NJ
07642-1054
US

V. Phone/Fax

Practice location:
  • Phone: 845-354-7108
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY STEVEN HERRING
Title or Position: PRESIDENT
Credential: MD
Phone: 201-888-0021