Provider Demographics
NPI:1912060153
Name:SOUTHSIDE FAMILY PHYSICIANS, INC
Entity Type:Organization
Organization Name:SOUTHSIDE FAMILY PHYSICIANS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MALUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-888-2811
Mailing Address - Street 1:8523 MADISON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-6115
Mailing Address - Country:US
Mailing Address - Phone:317-888-2811
Mailing Address - Fax:317-888-2822
Practice Address - Street 1:8523 MADISON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-6115
Practice Address - Country:US
Practice Address - Phone:317-888-2811
Practice Address - Fax:317-888-2822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100057680AMedicaid
INCB2083Medicare PIN
IN100057680AMedicaid