Basic Information
| Provider Information | |||||||||
| NPI: | 1588721435 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHSIDE GASTROENTEROLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 980 JOHNSON FERRY RD NE | ||||||||
| Address2: | SUITE 820 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042529307 | ||||||||
| FaxNumber: | 4042525839 | ||||||||
| Practice Location | |||||||||
| Address1: | 980 JOHNSON FERRY RD NE | ||||||||
| Address2: | SUITE 820 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042529307 | ||||||||
| FaxNumber: | 4042525839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 02/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | LUCAS | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4042529307 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 036306 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.