Provider Demographics
NPI:1477869337
Name:KIDMED SOUTHSIDE PLC
Entity Type:Organization
Organization Name:KIDMED SOUTHSIDE PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:FLANZENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-592-5437
Mailing Address - Street 1:4687 POUNCEY TRACT RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5802
Mailing Address - Country:US
Mailing Address - Phone:804-422-5437
Mailing Address - Fax:804-422-5438
Practice Address - Street 1:5021 CRAIG RATH BLVD
Practice Address - Street 2:BLDG IV
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-6243
Practice Address - Country:US
Practice Address - Phone:804-422-5437
Practice Address - Fax:804-422-5438
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIDMED INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAF16860Medicare UPIN
VAG39610Medicare UPIN
VAF87004Medicare UPIN