Provider Demographics
NPI:1386056216
Name:NORTHSIDE ONSITE MEDICAL SERVICES, INC.
Entity type:Organization
Organization Name:NORTHSIDE ONSITE MEDICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:THEAKSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-845-9355
Mailing Address - Street 1:211 GREENHILL BLVD NW
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35967-3755
Mailing Address - Country:US
Mailing Address - Phone:256-845-9355
Mailing Address - Fax:
Practice Address - Street 1:106 45TH ST NE
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35967-4010
Practice Address - Country:US
Practice Address - Phone:256-304-2109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHSIDE MEDICAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-27
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty