Basic Information
| Provider Information | |||||||||
| NPI: | 1427322882 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHSIDE OB-GYN PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16800 NW 2ND AVENUE | ||||||||
| Address2: | SUITE 601 | ||||||||
| City: | NORTH MIAMI BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331695549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7869556972 | ||||||||
| FaxNumber: | 3054636693 | ||||||||
| Practice Location | |||||||||
| Address1: | 16800 NW 2ND AVENUE | ||||||||
| Address2: | SUITE 601 | ||||||||
| City: | NORTH MIAMI BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331695549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7869556972 | ||||||||
| FaxNumber: | 3054636693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2012 | ||||||||
| LastUpdateDate: | 03/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | AMISIAL | ||||||||
| AuthorizedOfficialFirstName: | EDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7869556972 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | ME108552 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 004060500 | 05 | FL | MEDICAID |