Provider Demographics
NPI:1811208366
Name:ROADSIDE MEDICAL, LLC
Entity Type:Organization
Organization Name:ROADSIDE MEDICAL, LLC
Other - Org Name:ROADSIDE MEDICAL CLINIC AND LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:
Authorized Official - Last Name:WITHERSPOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-225-2520
Mailing Address - Street 1:8466 LOCKWOOD RIDGE RD
Mailing Address - Street 2:#248
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-2951
Mailing Address - Country:US
Mailing Address - Phone:941-225-2520
Mailing Address - Fax:888-860-8609
Practice Address - Street 1:400 S MORGAN RD
Practice Address - Street 2:BUILDING 1
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73128-7101
Practice Address - Country:US
Practice Address - Phone:405-603-3188
Practice Address - Fax:888-860-8609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center