Basic Information
| Provider Information | |||||||||
| NPI: | 1518952761 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHSIDE COMMUNITY HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CENTRA SOUTHSIDE COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 OAK ST | ||||||||
| Address2: | |||||||||
| City: | FARMVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 239011199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343928811 | ||||||||
| FaxNumber: | 4343152463 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 OAK ST | ||||||||
| Address2: | |||||||||
| City: | FARMVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 239011199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343928811 | ||||||||
| FaxNumber: | 4343152463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVENPORT | ||||||||
| AuthorizedOfficialFirstName: | DOUG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4342004708 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | H1904 | VA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 4900901 | 05 | VA | MEDICAID |