Basic Information
| Provider Information | |||||||||
| NPI: | 1194937235 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHSIDE MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 310 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726540310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704240899 | ||||||||
| FaxNumber: | 8704248455 | ||||||||
| Practice Location | |||||||||
| Address1: | 623 S 21ST ST | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729013914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794411500 | ||||||||
| FaxNumber: | 4794411502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PHAM | ||||||||
| AuthorizedOfficialFirstName: | THUYLINH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8704245079 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | E1751 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.