Provider Demographics
NPI:1659580215
Name:SOUTHSIDE PEDIATRICS
Entity Type:Organization
Organization Name:SOUTHSIDE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:S
Authorized Official - Last Name:IYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-565-3300
Mailing Address - Street 1:151 NORTH PARK TRAIL
Mailing Address - Street 2:SUITE A
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7373
Mailing Address - Country:US
Mailing Address - Phone:678-565-3300
Mailing Address - Fax:678-565-3311
Practice Address - Street 1:151 NORTH PARK TRAIL
Practice Address - Street 2:SUITE A
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7373
Practice Address - Country:US
Practice Address - Phone:678-565-3300
Practice Address - Fax:678-565-3311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042292208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty