Basic Information
| Provider Information | |||||||||
| NPI: | 1194803338 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHSIDE HEAD N NECK SURGERY PROFESSIONAL CORP | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTHSIDE EAR, NOSE & THROAT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 930 SOUTH AVE. | ||||||||
| Address2: | SUITE 4B | ||||||||
| City: | COLONIAL HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045040530 | ||||||||
| FaxNumber: | 8045040532 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 SOUTH AVE. | ||||||||
| Address2: | SUITE 4B | ||||||||
| City: | COLONIAL HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045040530 | ||||||||
| FaxNumber: | 8045040532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 07/01/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CANGCUESTA | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8043371110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 0101036702 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 040009007 | 01 | VA | MEDICARE RAILROAD | OTHER | P00002082 | 01 | VA | MEDICARE RAILROAD | OTHER | 006555055 | 01 | VA | MEDICARE RAILROAD | OTHER | P00002088 | 01 | VA | MEDICARE RAILROAD | OTHER |