Provider Demographics
NPI:1902670490
Name:SOUTHSIDE PSYCHIATRIC CONSULTANTS LLC
Entity Type:Organization
Organization Name:SOUTHSIDE PSYCHIATRIC CONSULTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:
Authorized Official - Last Name:OGWOTU
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:404-734-4666
Mailing Address - Street 1:110 W PIER WAY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4617
Mailing Address - Country:US
Mailing Address - Phone:404-734-4666
Mailing Address - Fax:
Practice Address - Street 1:6572 RIVER PARK DR STE 101
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2214
Practice Address - Country:US
Practice Address - Phone:404-734-4666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-14
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)