Provider Demographics
NPI:1871644047
Name:SOUTHSIDE PRIMARY CARE
Entity Type:Organization
Organization Name:SOUTHSIDE PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CARLISA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA-ROBLES
Authorized Official - Suffix:
Authorized Official - Credentials:RN, APNP
Authorized Official - Phone:414-384-5420
Mailing Address - Street 1:3053 W DREXEL AVE
Mailing Address - Street 2:UNIT 121
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-7923
Mailing Address - Country:US
Mailing Address - Phone:414-389-9992
Mailing Address - Fax:414-384-0134
Practice Address - Street 1:2727 W CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-2908
Practice Address - Country:US
Practice Address - Phone:414-384-5420
Practice Address - Fax:414-384-0134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2826033261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care