Provider Demographics
NPI:1063434272
Name:NORTHSIDE RADIATION ONCOLOGY PC
Entity type:Organization
Organization Name:NORTHSIDE RADIATION ONCOLOGY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-851-8850
Mailing Address - Street 1:PO BOX 932154
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-2154
Mailing Address - Country:US
Mailing Address - Phone:404-851-8850
Mailing Address - Fax:404-851-6010
Practice Address - Street 1:1000 JOHNSON FERRY RD NE
Practice Address - Street 2:NORTHSIDE HOSPITAL CANCER CENTER
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:404-851-8850
Practice Address - Fax:404-851-6010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00121122085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00144559HMedicaid
GA00144559HMedicaid
GAD42123Medicare UPIN
30BDJFDMedicare ID - Type Unspecified