Provider Demographics
NPI:1184798977
Name:SOUTHSIDE HOSPITAL
Entity type:Organization
Organization Name:SOUTHSIDE HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RPAC
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:RIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:RPAC
Authorized Official - Phone:631-853-2710
Mailing Address - Street 1:7 FARMHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-2169
Mailing Address - Country:US
Mailing Address - Phone:631-205-9626
Mailing Address - Fax:
Practice Address - Street 1:45 W SUFFOLK AVE
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-2143
Practice Address - Country:US
Practice Address - Phone:631-853-2710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006564-1261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care