Provider Demographics
NPI:1619180106
Name:SOUTHSIDE ASSISTANTS, INC.
Entity type:Organization
Organization Name:SOUTHSIDE ASSISTANTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C, MSN
Authorized Official - Phone:708-256-0816
Mailing Address - Street 1:21200 S LAGRANGE RD
Mailing Address - Street 2:SUITE 134
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-2003
Mailing Address - Country:US
Mailing Address - Phone:708-256-0816
Mailing Address - Fax:815-534-5576
Practice Address - Street 1:21200 S LAGRANGE RD
Practice Address - Street 2:SUITE 134
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-2003
Practice Address - Country:US
Practice Address - Phone:708-256-0816
Practice Address - Fax:815-534-5576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009090363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty