Provider Demographics
NPI:1407024557
Name:SOUTHSIDE OB/GYN, P.C.
Entity Type:Organization
Organization Name:SOUTHSIDE OB/GYN, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANCISCO
Authorized Official - Middle Name:A
Authorized Official - Last Name:DUENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-656-3533
Mailing Address - Street 1:PO BOX 1117
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-1117
Mailing Address - Country:US
Mailing Address - Phone:912-756-3404
Mailing Address - Fax:912-756-2156
Practice Address - Street 1:9390 FORD AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-6421
Practice Address - Country:US
Practice Address - Phone:912-756-3404
Practice Address - Fax:912-756-6352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP109Medicare PIN