Provider Demographics
NPI:1063402279
Name:NORTHSIDE IMAGING LLC
Entity type:Organization
Organization Name:NORTHSIDE IMAGING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAVELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-344-8203
Mailing Address - Street 1:6006 49TH ST N
Mailing Address - Street 2:STE 140
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-2148
Mailing Address - Country:US
Mailing Address - Phone:727-528-5900
Mailing Address - Fax:727-528-5911
Practice Address - Street 1:6006 49TH ST N
Practice Address - Street 2:STE 140
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-2148
Practice Address - Country:US
Practice Address - Phone:727-528-5900
Practice Address - Fax:727-528-5911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty