Provider Demographics
NPI:1487926978
Name:NORTHSIDE MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:NORTHSIDE MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:I
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-477-7144
Mailing Address - Street 1:4414 NORTH FWY STE 800
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77022-3662
Mailing Address - Country:US
Mailing Address - Phone:713-692-4200
Mailing Address - Fax:713-692-2253
Practice Address - Street 1:13211 WINDFERN RD STE C
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77064-3096
Practice Address - Country:US
Practice Address - Phone:281-477-7144
Practice Address - Fax:281-477-7448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-31
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty