Provider Demographics
NPI:1598905309
Name:SOUTHSIDE PULMONARY AND INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:SOUTHSIDE PULMONARY AND INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CORP.
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:B
Authorized Official - Last Name:KAISER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-447-3899
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:202 E. FERRELL ST.
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970
Mailing Address - Country:US
Mailing Address - Phone:434-447-3899
Mailing Address - Fax:434-447-7120
Practice Address - Street 1:202 E FERRELL ST
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-2104
Practice Address - Country:US
Practice Address - Phone:434-447-3899
Practice Address - Fax:434-447-7120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-06
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046990207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA086255OtherANTHEM
VA6007597Medicaid
VAE96509Medicare UPIN