Basic Information
| Provider Information | |||||||||
| NPI: | 1528253549 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHSIDE DIGESTIVE DISEASES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 W MEMORIAL RD | ||||||||
| Address2: | 901 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731209350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057494247 | ||||||||
| FaxNumber: | 4057494249 | ||||||||
| Practice Location | |||||||||
| Address1: | 4200 W MEMORIAL RD | ||||||||
| Address2: | 901 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731209350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057494247 | ||||||||
| FaxNumber: | 4057494249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2007 | ||||||||
| LastUpdateDate: | 10/31/2007 | ||||||||
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| AuthorizedOfficialLastName: | KAKISH | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | RANDALL | ||||||||
| AuthorizedOfficialTitleorPosition: | VIC PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4057494247 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.