Provider Demographics
NPI:1528253549
Name:NORTHSIDE DIGESTIVE DISEASES, INC.
Entity type:Organization
Organization Name:NORTHSIDE DIGESTIVE DISEASES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VIC PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:KAKISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-749-4247
Mailing Address - Street 1:4200 W MEMORIAL RD
Mailing Address - Street 2:901
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-9350
Mailing Address - Country:US
Mailing Address - Phone:405-749-4247
Mailing Address - Fax:405-749-4249
Practice Address - Street 1:4200 W MEMORIAL RD
Practice Address - Street 2:901
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-9350
Practice Address - Country:US
Practice Address - Phone:405-749-4247
Practice Address - Fax:405-749-4249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty