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General NPI Number Information
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NPI Number | 1265645063
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Entity Type | Organization
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Legal Business Name | NORTHSIDE MEDICAL SPECIALISTS
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Dates
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Enumeration Date | 05/08/2007
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Last Update Date | 06/30/2010
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Provider Practice Location Address
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Address Line | 145 RIVERSTONE TERRACE SUITE 100
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City | CANTON
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State | GA
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Zip | 30114-5257
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Country | US
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Telephone | 770-704-9499
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Fax | 770-704-9754
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Provider Business Mailing Address
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Address Line | 145 RIVERSTONE TERRACE SUITE 100
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City | CANTON
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State | GA
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Zip | 30114-5257
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Country | US
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Telephone | 770-704-9499
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Fax | 770-704-9754
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | CHRISTINA M SWAFFORD
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Credential |
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Telephone | 770-704-9499
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 046761
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 047083
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License Number State | GA
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