Provider Demographics
NPI:1780700765
Name:SOUTHSIDE FAMILY PRACTICE P.C.
Entity type:Organization
Organization Name:SOUTHSIDE FAMILY PRACTICE P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIRLENE
Authorized Official - Middle Name:TOLBERT
Authorized Official - Last Name:MOTEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-733-3739
Mailing Address - Street 1:24 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-4525
Mailing Address - Country:US
Mailing Address - Phone:804-733-3739
Mailing Address - Fax:804-722-0634
Practice Address - Street 1:24 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-4525
Practice Address - Country:US
Practice Address - Phone:804-733-3739
Practice Address - Fax:804-722-0634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2008-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005637686Medicaid
VA005637686Medicaid
VAF78265Medicare UPIN