Provider Demographics
NPI:1821356528
Name:SOUTHSIDE PSYCHIATRIC ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:SOUTHSIDE PSYCHIATRIC ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LYLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-506-8187
Mailing Address - Street 1:7444 HANNOVER PKWY S
Mailing Address - Street 2:STE. 200
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9303
Mailing Address - Country:US
Mailing Address - Phone:770-506-8187
Mailing Address - Fax:770-506-7436
Practice Address - Street 1:7444 HANNOVER PKWY S
Practice Address - Street 2:STE. 200
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9303
Practice Address - Country:US
Practice Address - Phone:770-506-8187
Practice Address - Fax:770-506-7436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0247072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1568573871Medicare PIN