1588088025 NPI number — SOUTHSIDE MEDICAL CENTER, INC.

Table of content: MS. SHERYL LYNN HALL CRNA (NPI 1467481937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588088025 NPI number — SOUTHSIDE MEDICAL CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHSIDE MEDICAL CENTER, 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:
1588088025
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1046 RIDGE AVE SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30315-1640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-688-1350
Provider Business Mailing Address Fax Number:
404-688-2962

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
176 LYONS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30233-2134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-688-1350
Provider Business Practice Location Address Fax Number:
404-688-2962
Provider Enumeration Date:
02/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
404-688-1350

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000444056O , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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