Provider Demographics
NPI:1811146194
Name:SOUTHSIDE PHYSICIAN NETWORK LLC
Entity type:Organization
Organization Name:SOUTHSIDE PHYSICIAN NETWORK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-765-5473
Mailing Address - Street 1:436 CLAIRMONT CT
Mailing Address - Street 2:SUITE 105
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-1765
Mailing Address - Country:US
Mailing Address - Phone:804-765-5363
Mailing Address - Fax:804-765-6490
Practice Address - Street 1:436 CLAIRMONT CT
Practice Address - Street 2:SUITE 105
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834
Practice Address - Country:US
Practice Address - Phone:804-765-5473
Practice Address - Fax:804-765-6490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-11
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA208600000X, 231H00000X, 207RC0000X
2086S0129X, 208800000X, 208D00000X, 208G00000X, 207Q00000X, 207V00000X, 207X00000X, 207Y00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1811146194Medicaid
VAGC1082Medicare PIN