Provider Demographics
NPI:1902913767
Name:NORTHSIDE SURGICAL SPECIALISTS, PC
Entity Type:Organization
Organization Name:NORTHSIDE SURGICAL SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-875-0112
Mailing Address - Street 1:PO BOX 68952
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-0952
Mailing Address - Country:US
Mailing Address - Phone:317-802-3112
Mailing Address - Fax:317-870-0499
Practice Address - Street 1:8424 NAAB RD
Practice Address - Street 2:SUITE #2F
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-5918
Practice Address - Country:US
Practice Address - Phone:317-875-0112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100441520Medicaid
IN100441520Medicaid