Basic Information
| Provider Information | |||||||||
| NPI: | 1609390103 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAK ANESTHESIA NORTHSIDE AFFILIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1635 OLD 41 HWY. NW | ||||||||
| Address2: | STE. 112-328 | ||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707021806 | ||||||||
| FaxNumber: | 7706930810 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 RIDENOUR BLVD NW STE 300 | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301524402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707021806 | ||||||||
| FaxNumber: | 7706930810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | WEIGANDT | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7707021806 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.