1760589287 NPI number — SOUTHSIDE MEDICAL ASSOCIATES P.C

Table of content: (NPI 1760589287)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760589287 NPI number — SOUTHSIDE MEDICAL ASSOCIATES P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHSIDE MEDICAL ASSOCIATES P.C
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:
1760589287
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2202-A BEECHMONT ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BOSTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24592-2547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-575-6300
Provider Business Mailing Address Fax Number:
434-575-8300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2202-A BEECHMONT ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BOSTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24592-2547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-575-6300
Provider Business Practice Location Address Fax Number:
434-575-8300
Provider Enumeration Date:
09/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
SHERRY
Authorized Official Middle Name:
LENE
Authorized Official Title or Position:
M.D
Authorized Official Telephone Number:
434-575-6300

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  0101023654 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 010141405 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 110244240 . This is a "RR MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 005880777 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 005880769 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110244239 . This is a "RR MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 44111 . This is a "OPTIMA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 20602 . This is a "OPTIMA" identifier . This identifiers is of the category "OTHER".




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