Provider Demographics
NPI:1518952761
Name:SOUTHSIDE COMMUNITY HOSPITAL, INC.
Entity Type:Organization
Organization Name:SOUTHSIDE COMMUNITY HOSPITAL, INC.
Other - Org Name:CENTRA SOUTHSIDE COMMUNITY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-200-4708
Mailing Address - Street 1:800 OAK ST
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-1199
Mailing Address - Country:US
Mailing Address - Phone:434-392-8811
Mailing Address - Fax:434-315-2463
Practice Address - Street 1:800 OAK ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-1199
Practice Address - Country:US
Practice Address - Phone:434-392-8811
Practice Address - Fax:434-315-2463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH1904282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4900901Medicaid
VA4900901Medicaid