Provider Demographics
NPI:1679781314
Name:SOUTHSIDE PULMONARY & SLEEP CONSULTANTS, LLC
Entity Type:Organization
Organization Name:SOUTHSIDE PULMONARY & SLEEP CONSULTANTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:HANK
Authorized Official - Last Name:WOOLDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-893-0888
Mailing Address - Street 1:1040 GREENWOOD SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7975
Mailing Address - Country:US
Mailing Address - Phone:317-893-0888
Mailing Address - Fax:317-893-0815
Practice Address - Street 1:1040 GREENWOOD SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-7975
Practice Address - Country:US
Practice Address - Phone:317-893-0888
Practice Address - Fax:317-893-0815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & ImmunologyGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200530370Medicaid
IN221970Medicare ID - Type Unspecified