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General NPI Number Information
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NPI Number | 1891836342
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Entity Type | Organization
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Legal Business Name | NORTHSIDE BARIATRIC SURGERY CENTER
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Dates
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Enumeration Date | 02/09/2007
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Last Update Date | 11/23/2020
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Provider Practice Location Address
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Address Line | 960 JOHNSON FERRY RD NE SUITE 228
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City | ATLANTA
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State | GA
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Zip | 30342-1631
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Country | US
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Telephone | 404-252-2220
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Fax | 404-252-4530
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Provider Business Mailing Address
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Address Line | 960 JOHNSON FERRY RD NE SUITE 228
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City | ATLANTA
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State | GA
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Zip | 30342-1631
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Country | US
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Telephone | 404-252-2220
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Fax | 404-252-4530
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Authorized Official
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Title or Position | OFFICE ADMINISTRATOR
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Name | TIFANY BOSTWICK
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Credential |
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Telephone | 404-252-2220
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 37604
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License Number State | GA
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