Provider Demographics
NPI:1659726875
Name:SOUTH SIDE CLINIC
Entity Type:Organization
Organization Name:SOUTH SIDE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SKILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-507-9517
Mailing Address - Street 1:1831 PITTSTON AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-1651
Mailing Address - Country:US
Mailing Address - Phone:570-507-9517
Mailing Address - Fax:
Practice Address - Street 1:1831 PITTSTON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-1651
Practice Address - Country:US
Practice Address - Phone:570-507-9517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207Q00000X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty