MEDICARE: NORTHSIDE HOSPITAL

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	333600000X	Pharmacy	PHRE007472	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1151404	OTHER	GA	NABP AKA NCPDP#

General Provider Information

NPI Number	:	1487653283
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE HOSPITAL

Provider Business Mailing Address
First Line	:	1200 NORTHSIDE FORSYTH DR
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30041-7659
Country	:	US
Telephone Number	:	770-844-3396
Fax Number	:	770-844-3397

Provider Business Practice Location Address
First Line	:	1200 NORTHSIDE FORSYTH DR
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30041-7659
Country	:	US
Telephone Number	:	770-844-3396
Fax Number	:	770-844-3397

Authorized Official
Title or Position	:	DIRECTOR OF PHARMACY
Name	:	MRS. RAE LYNN BENTON
Credential	:	RPH
Telephone Number	:	770-844-3291

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	08/22/2020

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1356333868 — NORTHSIDE HOSPITAL
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30041-7659

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Directions to “NORTHSIDE HOSPITAL ” Practice Location

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