Provider Demographics
NPI:1568413656
Name:SOUTHSIDE MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:SOUTHSIDE MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-770-2281
Mailing Address - Street 1:1900 S. CLINTON AVE STE 320 ROCH. NY 14618
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-5719
Mailing Address - Country:US
Mailing Address - Phone:585-271-7141
Mailing Address - Fax:585-419-6163
Practice Address - Street 1:1900 S. CLINTON AVE. STE 320
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-5719
Practice Address - Country:US
Practice Address - Phone:585-271-7141
Practice Address - Fax:585-419-6163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-13
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY182719GDOtherPREFERRED CARE
NY84VMedicaid
NY7273762OtherAETNA HEALTH, INC
NY02742689Medicaid
NYP0170059SSOtherEXCELLUS BLUE CROSS
NY182719GDOtherPREFERRED CARE
NY02742689Medicaid
NYP0170059SSOtherEXCELLUS BLUE CROSS