Provider Demographics
NPI:1740583194
Name:SOUTHSIDE INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:SOUTHSIDE INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CASIMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:OKORO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-997-6644
Mailing Address - Street 1:7384 HIGHWAY 85
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-3453
Mailing Address - Country:US
Mailing Address - Phone:770-997-6644
Mailing Address - Fax:770-997-6630
Practice Address - Street 1:804 COMMERCE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-7198
Practice Address - Country:US
Practice Address - Phone:770-997-6644
Practice Address - Fax:770-997-6630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-07
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000544948JMedicaid
GA000544948JMedicaid
F59027Medicare UPIN