Provider Demographics
NPI:1508201385
Name:SOUTHSIDE KIDNEY SPECIALISTS
Entity Type:Organization
Organization Name:SOUTHSIDE KIDNEY SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIJAYA
Authorized Official - Middle Name:LAKSHMI
Authorized Official - Last Name:CHIRUMAMILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-733-6960
Mailing Address - Street 1:201 E. FERRELL ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-2202
Mailing Address - Country:US
Mailing Address - Phone:434-447-3455
Mailing Address - Fax:434-447-3405
Practice Address - Street 1:3400 S CRATER RD
Practice Address - Street 2:STE #B
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9252
Practice Address - Country:US
Practice Address - Phone:804-733-6960
Practice Address - Fax:804-733-3880
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHSIDE KIDNEY SPECIALISTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty