Provider Demographics
NPI:1629247341
Name:SOUTHSIDE UROLOGY CLINIC, P.C.
Entity Type:Organization
Organization Name:SOUTHSIDE UROLOGY CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAJENDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:MOTWANI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:405-632-4500
Mailing Address - Street 1:9817 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-2812
Mailing Address - Country:US
Mailing Address - Phone:405-632-4500
Mailing Address - Fax:405-632-7500
Practice Address - Street 1:9817 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-2812
Practice Address - Country:US
Practice Address - Phone:405-632-4500
Practice Address - Fax:405-632-7500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3478174400000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200620340AMedicaid
OK464291Medicare PIN