1578602694 NPI number — SOUTHSIDE INTERNAL MEDICINE PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578602694 NPI number — SOUTHSIDE INTERNAL MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHSIDE INTERNAL MEDICINE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578602694
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8778 MADISON AVE
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46227-7204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-881-0677
Provider Business Mailing Address Fax Number:
317-881-0690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8778 MADISON AVE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46227-7204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-881-0677
Provider Business Practice Location Address Fax Number:
317-881-0690
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SLATER
Authorized Official First Name:
WANDA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
317-881-0677

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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