Basic Information
| Provider Information | |||||||||
| NPI: | 1538137757 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHSIDE COMMUNITY HEALTH SERVICES, INC. | ||||||||
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| OtherOrganizationName: | SOUTHSIDE MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4243 4TH AVE S | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554092113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128212799 | ||||||||
| FaxNumber: | 6128212818 | ||||||||
| Practice Location | |||||||||
| Address1: | 324 E 35TH ST | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554084580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128277181 | ||||||||
| FaxNumber: | 6128276403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 04/30/2014 | ||||||||
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| AuthorizedOfficialLastName: | TENDLE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | HENRY | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6128212800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 343814700 | 05 | MN | MEDICAID |