Provider Demographics
NPI:1689090839
Name:SOUTHSIDE MEDICAL MANAGEMENT INC
Entity Type:Organization
Organization Name:SOUTHSIDE MEDICAL MANAGEMENT INC
Other - Org Name:KENBRIDGE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GRAHAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:434-584-2000
Mailing Address - Street 1:306 E 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:23944-2050
Mailing Address - Country:US
Mailing Address - Phone:434-676-8021
Mailing Address - Fax:434-447-2240
Practice Address - Street 1:306 E 6TH AVE
Practice Address - Street 2:
Practice Address - City:KENBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:23944-2050
Practice Address - Country:US
Practice Address - Phone:434-676-8021
Practice Address - Fax:434-447-2240
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHSIDE MEDICAL MANAGEMENT INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-12
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
VA0024168641363LA2200X
VA363LF0000X
VA0024168845363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05459Medicare PIN