1568413656 NPI number — SOUTHSIDE MEDICAL SUPPLY, LLC

Table of content: (NPI 1568413656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568413656 NPI number — SOUTHSIDE MEDICAL SUPPLY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHSIDE MEDICAL SUPPLY, LLC
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:
1568413656
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 S. CLINTON AVE STE 320 ROCH. NY 14618
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14618-5719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-271-7141
Provider Business Mailing Address Fax Number:
585-419-6163

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 S. CLINTON AVE. STE 320
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14618-5719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-271-7141
Provider Business Practice Location Address Fax Number:
585-419-6163
Provider Enumeration Date:
05/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOLES
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
585-770-2281

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 182719GD . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 84V , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7273762 . This is a "AETNA HEALTH, INC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02742689 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P0170059SS . This is a "EXCELLUS BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com