MEDICARE: NORTHSIDE URGENT CARE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1427155043
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE URGENT CARE INC

Provider Business Mailing Address
First Line	:	1701 N MAIN ST
Second Line	:	SUITE E
City	:	SHELBYVILLE
State	:	TN
Zip	:	37160-2303
Country	:	US
Telephone Number	:	931-684-1990
Fax Number	:	931-680-5602

Provider Business Practice Location Address
First Line	:	1701 N MAIN ST
Second Line	:	SUITE E
City	:	SHELBYVILLE
State	:	TN
Zip	:	37160-2303
Country	:	US
Telephone Number	:	931-684-1990
Fax Number	:	931-680-5602

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. FRANK L JAYAKODY
Credential	:	MD
Telephone Number	:	931-684-1990

Provider Enumeration Date	:	09/17/2006
Last Update Date	:	08/22/2020

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