Provider Demographics
NPI:1205968799
Name:SOUTHSIDE PODIATRY PC
Entity type:Organization
Organization Name:SOUTHSIDE PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ELLIOTT
Authorized Official - Last Name:HUPART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-241-2000
Mailing Address - Street 1:903 E 82ND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-3811
Mailing Address - Country:US
Mailing Address - Phone:718-241-2000
Mailing Address - Fax:718-241-5281
Practice Address - Street 1:903 E 82ND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236
Practice Address - Country:US
Practice Address - Phone:718-241-2000
Practice Address - Fax:718-241-5281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-10
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN002003-1213E00000X
NYN004686213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01522036Medicaid
NY01180363Medicaid
NY=========OtherGHI
NY=========OtherAPWU
NY=========OtherHIP
NY=========OtherBLUE CROSS
NY=========OtherEMPIRE PLAN
NY=========OtherCIGNA
NY=========OtherAMEICHOICE
NY01180363Medicaid
NY=========OtherUNITED HEALTH CARE
NY=========Other1199
NY=========OtherBLUE SHEILD
NY=========OtherAETNA
NY=========OtherAARP
NY=========OtherEVERCARE
NYU18041Medicare UPIN
NYP5W62Medicare ID - Type Unspecified
NY01522036Medicaid