Provider Demographics
NPI:1356681845
Name:SOUTHSIDE MEDICAL CLINIC
Entity Type:Organization
Organization Name:SOUTHSIDE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SUARES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-688-9219
Mailing Address - Street 1:1707 E EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-3470
Mailing Address - Country:US
Mailing Address - Phone:863-688-9219
Mailing Address - Fax:863-687-4863
Practice Address - Street 1:1707 E EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-3470
Practice Address - Country:US
Practice Address - Phone:863-688-9219
Practice Address - Fax:863-687-4863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0043239261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD62005Medicare UPIN