Provider Demographics
NPI:1447698964
Name:GEORGIA NORTHSIDE EAR, NOSE AND THROAT, LLC
Entity type:Organization
Organization Name:GEORGIA NORTHSIDE EAR, NOSE AND THROAT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL CFO, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:O
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-265-5009
Mailing Address - Street 1:PO BOX 742566
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2105
Mailing Address - Country:US
Mailing Address - Phone:770-475-3361
Mailing Address - Fax:770-664-4431
Practice Address - Street 1:1360 UPPER HEMBREE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1171
Practice Address - Country:US
Practice Address - Phone:770-475-3361
Practice Address - Fax:770-664-4431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-06
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Multi-Specialty