Provider Demographics
NPI:1568453322
Name:WHITESIDES, ROBERT F JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:F
Last Name:WHITESIDES
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1547
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65302-1547
Mailing Address - Country:US
Mailing Address - Phone:660-826-5960
Mailing Address - Fax:660-826-4852
Practice Address - Street 1:2829 E HIGHWAY 76
Practice Address - Street 2:
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574-6035
Practice Address - Country:US
Practice Address - Phone:843-431-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC79802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890627IMedicaid
SC079809Medicaid
SC079809Medicaid
NC890627IMedicaid