Provider Demographics
NPI:1093938490
Name:SOUTHSIDE UROLOGY CLINIC PC
Entity Type:Organization
Organization Name:SOUTHSIDE UROLOGY CLINIC PC
Other - Org Name:THE SOUTHSIDE UROLOGY CLINIC, PC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER /PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-392-9449
Mailing Address - Street 1:PO BOX 347
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-0347
Mailing Address - Country:US
Mailing Address - Phone:434-392-9449
Mailing Address - Fax:434-392-5530
Practice Address - Street 1:800 OAK ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-1199
Practice Address - Country:US
Practice Address - Phone:434-392-9449
Practice Address - Fax:434-392-5530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101037122208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1528066297OtherPHYSICIAN NPI
VA1528066297Medicaid
CM5051OtherRAILROAD MEDICARE GROUP #
340001025OtherRAILROAD MEDICARE PIN
1528066297OtherPHYSICIAN NPI