Provider Demographics
NPI:1841479565
Name:CENTRA MEDICAL GROUP SOUTHSIDE, LLC
Entity type:Organization
Organization Name:CENTRA MEDICAL GROUP SOUTHSIDE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-392-8811
Mailing Address - Street 1:2010 ATHERHOLT RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 OAK ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-1199
Practice Address - Country:US
Practice Address - Phone:434-200-3656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA345608OtherANTHEM BCBS (312 KING STREET)
VA61459600OtherBLACK LUNG/FECA (STE 3105)
VA61459602OtherBLACK LUNG/FECA (412 NAMOZINE STR)
VA61459604OtherBLACK LUNG/FECA (1418 6TH ST)
VA345604OtherANTHEM BCBS (800 OAK STREET)
VA345307OtherANTHEM, BCBS (1418 6TH STREET)
VA345606OtherANTHEM BCBS (412 NAMOZINE STREET)
VA61459601OtherBLACK LUNG/FECA (312 KING ST)
VA61459603OtherBLACK LUNG/FECA (1705 3RD ST)
VA1841479565Medicaid
VA9978134OtherAETNA
VA345307OtherANTHEM, BCBS (1418 6TH STREET)
VA61459603OtherBLACK LUNG/FECA (1705 3RD ST)