Provider Demographics
NPI:1073177978
Name:SOUTHSIDE MEDICAL PRACTICE PLLC
Entity Type:Organization
Organization Name:SOUTHSIDE MEDICAL PRACTICE PLLC
Other - Org Name:SOUTHSIDE MEDICAL PRACTICE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-392-9438
Mailing Address - Street 1:502 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-1222
Mailing Address - Country:US
Mailing Address - Phone:434-392-9438
Mailing Address - Fax:434-392-7630
Practice Address - Street 1:502 BEECH ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-1222
Practice Address - Country:US
Practice Address - Phone:434-392-9438
Practice Address - Fax:434-392-7630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-25
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty