Provider Demographics
NPI:1568651719
Name:SOUTHSIDE AREA FAMILY MEDICINE INC
Entity Type:Organization
Organization Name:SOUTHSIDE AREA FAMILY MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:WILEY
Authorized Official - Last Name:CORBETT
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:434-392-9366
Mailing Address - Street 1:324 COMMERCE RD
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-2794
Mailing Address - Country:US
Mailing Address - Phone:434-392-9366
Mailing Address - Fax:434-392-9348
Practice Address - Street 1:324 COMMERCE RD
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-2794
Practice Address - Country:US
Practice Address - Phone:434-392-9366
Practice Address - Fax:434-392-9348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057605207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010299161Medicaid
VA20416OtherSENTARA
VA187087OtherANTHEM
VA7722441OtherAETNA
VAP00326033OtherMEDICARE RAILROAD
VAP00326033OtherMEDICARE RAILROAD
VA010299161Medicaid