Provider Demographics
NPI:1033130026
Name:SOUTHSIDE KIDNEY SPECIALISTS
Entity Type:Organization
Organization Name:SOUTHSIDE KIDNEY SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VIJAYA
Authorized Official - Middle Name:LAKSHMI
Authorized Official - Last Name:CHIRUMAMILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-733-6960
Mailing Address - Street 1:3400 S CRATER RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9211
Mailing Address - Country:US
Mailing Address - Phone:804-733-6960
Mailing Address - Fax:804-733-3880
Practice Address - Street 1:3400 S CRATER RD
Practice Address - Street 2:SUITE B
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9211
Practice Address - Country:US
Practice Address - Phone:804-733-6960
Practice Address - Fax:804-733-3880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09290Medicare ID - Type Unspecified