Provider Demographics
NPI:1760589287
Name:SOUTHSIDE MEDICAL ASSOCIATES P.C
Entity Type:Organization
Organization Name:SOUTHSIDE MEDICAL ASSOCIATES P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:LENE
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-575-6300
Mailing Address - Street 1:2202-A BEECHMONT ROAD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-2547
Mailing Address - Country:US
Mailing Address - Phone:434-575-6300
Mailing Address - Fax:434-575-8300
Practice Address - Street 1:2202-A BEECHMONT ROAD
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-2547
Practice Address - Country:US
Practice Address - Phone:434-575-6300
Practice Address - Fax:434-575-8300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-19
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101023654207R00000X
VA010141405207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA110244240OtherRR MEDICARE
VA005880777Medicaid
VA005880769Medicaid
VA110244239OtherRR MEDICARE
44111OtherOPTIMA
20602OtherOPTIMA
20602OtherOPTIMA
VA110244239OtherRR MEDICARE
VA110244240OtherRR MEDICARE
C08477Medicare UPIN
VA005880777Medicaid