Provider Demographics
NPI:1578680872
Name:SOUTHSIDE COMMUNITY HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:SOUTHSIDE COMMUNITY HEALTH SERVICES, INC.
Other - Org Name:ST. CROIX FAMILY MEDICAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:TENDLE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:612-821-2800
Mailing Address - Street 1:4243 4TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55409-2113
Mailing Address - Country:US
Mailing Address - Phone:612-822-9030
Mailing Address - Fax:612-821-2818
Practice Address - Street 1:5640 MEMORIAL AVE N
Practice Address - Street 2:SUITE B
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-2166
Practice Address - Country:US
Practice Address - Phone:651-430-1880
Practice Address - Fax:651-430-1323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN943170500Medicaid
MNC00626Medicare PIN