Basic Information
| Provider Information | |||||||||
| NPI: | 1700121084 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHSIDE MEDICAL CLINIC AT THE ADLER CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4243 4TH AVE S | ||||||||
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| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554092113 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 416 E HENNEPIN AVE | ||||||||
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| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554141006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128229030 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2012 | ||||||||
| LastUpdateDate: | 04/30/2014 | ||||||||
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| AuthorizedOfficialLastName: | TENDLE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | HENRY | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6128212800 | ||||||||
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| 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 |
No ID Information.