Organization
NORTHSIDE CHILDREN'S PEDIATRIC CENTER, LLC
Active
Other names
Northside Children's Pediatrics Center, PC
Organization subpart
No
Provider details
NPI number
Authorized official
PROF. STEPHANIE HEATON ANDERSON DNP, PNP, RNC (RN-PNP, MEMBER, AND (SPOUSE OF MD))
(770) 720-6963
Entity
Organization
Contact information
Practice address
391 EAST MAIN STREET, HISTORIC HAWKINS BUILDING, CANTON, GA 30114-2712
(770) 720-6963
(770) 720-6965
Mailing address
391 EAST MAIN STREET, HISTORIC HAWKINS BUILDING, CANTON, GA 30114-2712
(770) 720-6963
(770) 720-6965
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
GA 54532
GA
261QP2300X
Primary Care Clinic/Center
GA PHYSICIAN 54532
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1396945515
AUTH REPRESENTATIVE: MICHAEL G. ANDERSON, MD, ENTITY ATTENDING PHYSICIAN
GA
05
—
629697125A
—
GA
Enumeration date
07/25/2007
Last updated
01/24/2012
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