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General NPI Number Information
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NPI Number | 1265401681
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Entity Type | Organization
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Legal Business Name | NORTHSIDE MEDICAL CENTER, PLC
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Dates
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Enumeration Date | 03/16/2006
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Last Update Date | 12/08/2008
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Provider Practice Location Address
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Address Line | 465 EASTVOLD AVE
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City | ORTONVILLE
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State | MN
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Zip | 56278-1107
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Country | US
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Telephone | 320-839-6157
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Fax | 320-839-3851
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Provider Business Mailing Address
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Address Line | 465 EASTVOLD AVE
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City | ORTONVILLE
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State | MN
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Zip | 56278-1107
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Country | US
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Telephone | 320-839-6157
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Fax | 320-839-3851
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Authorized Official
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Title or Position | CLINIC ADMINISTRATOR
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Name | LIZ M SORENSON
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Credential |
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Telephone | 320-839-6157
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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