Provider Demographics
NPI:1215024674
Name:SOUTHSIDE FAMILY MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:SOUTHSIDE FAMILY MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-452-8400
Mailing Address - Street 1:5955 S EMERSON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-2600
Mailing Address - Country:US
Mailing Address - Phone:317-452-8400
Mailing Address - Fax:317-452-8484
Practice Address - Street 1:5955 S EMERSON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-2600
Practice Address - Country:US
Practice Address - Phone:317-789-9600
Practice Address - Fax:317-789-0600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
219130Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER