Provider Demographics
NPI:1578602694
Name:SOUTHSIDE INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:SOUTHSIDE INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SLATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-881-0677
Mailing Address - Street 1:8778 MADISON AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-7204
Mailing Address - Country:US
Mailing Address - Phone:317-881-0677
Mailing Address - Fax:317-881-0690
Practice Address - Street 1:8778 MADISON AVE
Practice Address - Street 2:STE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-7204
Practice Address - Country:US
Practice Address - Phone:317-881-0677
Practice Address - Fax:317-881-0690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty