NPIMap

Organization Active NPI

Northside Children's Pediatric Center, LLC

  • Pediatrics Physician
  • Canton, GA
National Provider Identifier
1396945515
Registry record updated Jan 24, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
License
GA 54532 Issued in GA
Legal business name
NORTHSIDE CHILDREN'S PEDIATRIC CENTER, LLC
Practice address
391 East Main Street
Historic Hawkins Building
Canton, GA 30114-2712
Phone
(770) 720-6963
Fax
(770) 720-6965
NPI assigned
Jul 25, 2007
Last updated
Jan 24, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 24, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Prof. Stephanie Heaton Anderson, DNP, PNP, RNCNPI 1609087972
Title
RN-PNP, Member, and (Spouse of MD)
Phone
(770) 720-6963

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X GA PHYSICIAN 54532 GA
Pediatrics Physician 208000000X GA 54532 GA Primary

Addresses

Primary practice location

391 East Main Street
Historic Hawkins Building
Canton, GA 30114-2712

Mailing address

391 East Main Street
Historic Hawkins Building
Canton, GA 30114-2712
Phone (770) 720-6963

Other identifiers 2

IdentifierTypeStateIssuer
1396945515OtherGAAUTH REPRESENTATIVE: MICHAEL G. ANDERSON, MD, ENTITY ATTENDING PHYSICIAN
629697125AMedicaidGA

Other names 1

  • Northside Children's Pediatrics Center, PC Former legal business name

National Provider Directory

National Provider Directory

Locations

391 E Main St
Canton, GA 30114
Phone (770) 720-6963

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1185321600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1327363200000",
    "number": "1396945515",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "391 EAST MAIN STREET",
            "address_2": "HISTORIC HAWKINS BUILDING",
            "city": "CANTON",
            "state": "GA",
            "postal_code": "301142712",
            "telephone_number": "770-720-6963",
            "fax_number": "770-720-6965"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "391 EAST MAIN STREET",
            "address_2": "HISTORIC HAWKINS BUILDING",
            "city": "CANTON",
            "state": "GA",
            "postal_code": "301142712",
            "telephone_number": "770-720-6963",
            "fax_number": "770-720-6965"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHSIDE CHILDREN'S PEDIATRIC CENTER, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-07-25",
        "last_updated": "2012-01-24",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "STEPHANIE",
        "authorized_official_middle_name": "HEATON",
        "authorized_official_title_or_position": "RN-PNP, MEMBER, AND  (SPOUSE OF MD)",
        "authorized_official_telephone_number": "770-720-6963",
        "authorized_official_name_prefix": "Prof.",
        "authorized_official_credential": "DNP, PNP, RNC"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "GA",
            "license": "GA PHYSICIAN 54532",
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "GA",
            "license": "GA 54532",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AUTH REPRESENTATIVE: MICHAEL G. ANDERSON, MD, ENTITY ATTENDING PHYSICIAN",
            "identifier": "1396945515",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "629697125A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Northside Children's Pediatrics Center, PC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Canton, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 24, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.