Provider Demographics
NPI:1609065341
Name:SOUTHSIDE INTERNAL MEDICINE, PC
Entity Type:Organization
Organization Name:SOUTHSIDE INTERNAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-392-6143
Mailing Address - Street 1:202 AGEE STREET
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901
Mailing Address - Country:US
Mailing Address - Phone:434-392-6143
Mailing Address - Fax:434-392-3866
Practice Address - Street 1:202 AGEE STREET
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901
Practice Address - Country:US
Practice Address - Phone:434-392-6143
Practice Address - Fax:434-392-3866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048599302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005849632Medicaid
VA110004643Medicare PIN