Provider Demographics
NPI:1063628675
Name:SOUTHSIDE MEDICAL & PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:SOUTHSIDE MEDICAL & PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOBEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-476-8913
Mailing Address - Street 1:1415 HIGHWAY 85 N
Mailing Address - Street 2:SUITE 310-314
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4035
Mailing Address - Country:US
Mailing Address - Phone:866-476-8913
Mailing Address - Fax:
Practice Address - Street 1:1415 HIGHWAY 85 N
Practice Address - Street 2:SUITE 310-314
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4035
Practice Address - Country:US
Practice Address - Phone:866-476-8913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054590208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty