Provider Demographics
NPI:1346356631
Name:SOUTHSIDE EMERGENCY PHYSICIANS PC
Entity Type:Organization
Organization Name:SOUTHSIDE EMERGENCY PHYSICIANS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CECIL
Authorized Official - Middle Name:F
Authorized Official - Last Name:HAZELWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-517-3515
Mailing Address - Street 1:PO BOX 1115
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1115
Mailing Address - Country:US
Mailing Address - Phone:434-517-3515
Mailing Address - Fax:434-572-4549
Practice Address - Street 1:2204 WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1645
Practice Address - Country:US
Practice Address - Phone:434-517-3832
Practice Address - Fax:434-517-3649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response AttendantGroup - Single Specialty