Organization Name: | NORTHSIDE MEDICAL, INC. |
NPI Number: | 1205089372 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | ROBERT W. THEAKSTON (PRESIDENT) |
Mailing Address: | 211 Greenhill Blvd Nw Fort Payne |
State: | AL US |
Postal Code: | 359673755 |
Phone Number: | 2568459355 |
Fax Number: | |
NPI Enumeration Date: | 11/02/2008 |
NPI Last Update Date: | 11/02/2008 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QP2300X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Primary Care |
Taxonomy Definition: |