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General NPI Number Information
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NPI Number | 1538286091
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Entity Type | Organization
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Legal Business Name | NORTHSIDE CLINIC
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Dates
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Enumeration Date | 03/22/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2211 N 13TH ST
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City | KANSAS CITY
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State | KS
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Zip | 66104-5649
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Country | US
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Telephone | 913-233-1911
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Fax | 913-321-5185
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Provider Business Mailing Address
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Address Line | 2211 N 13TH ST
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City | KANSAS CITY
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State | KS
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Zip | 66104-5649
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Country | US
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Telephone | 913-233-1911
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Fax | 913-321-5185
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. MARVIN MCINTOSH
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Credential | M.D.
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Telephone | 913-233-1911
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 0428352
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License Number State | KS
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