1578680872 NPI number — SOUTHSIDE COMMUNITY HEALTH SERVICES, INC.

Table of content: (NPI 1578680872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578680872 NPI number — SOUTHSIDE COMMUNITY HEALTH SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHSIDE COMMUNITY HEALTH SERVICES, INC.
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:
6
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:
1578680872
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4243 4TH AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55409-2113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-822-9030
Provider Business Mailing Address Fax Number:
612-821-2818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5640 MEMORIAL AVE N
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
STILLWATER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55082-2166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-430-1880
Provider Business Practice Location Address Fax Number:
651-430-1323
Provider Enumeration Date:
03/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TENDLE
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
HENRY
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
612-821-2800

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 943170500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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