Provider Demographics
NPI:1912252909
Name:SOUTHSIDE PEDIATRICS PC
Entity Type:Organization
Organization Name:SOUTHSIDE PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILGUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-818-1020
Mailing Address - Street 1:300 MEADOW RUN DR
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-9048
Mailing Address - Country:US
Mailing Address - Phone:269-818-1020
Mailing Address - Fax:269-818-1266
Practice Address - Street 1:300 MEADOW RUN DR
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-9048
Practice Address - Country:US
Practice Address - Phone:269-818-1020
Practice Address - Fax:269-818-1266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073703208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4123869Medicaid