Basic Information
| Provider Information | |||||||||
| NPI: | 1841479565 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRA MEDICAL GROUP SOUTHSIDE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2010 ATHERHOLT RD | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245011106 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 OAK ST | ||||||||
| Address2: | |||||||||
| City: | FARMVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 239011199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4342003656 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2007 | ||||||||
| LastUpdateDate: | 08/07/2014 | ||||||||
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| AuthorizedOfficialLastName: | BASS | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4343928811 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 345608 | 01 | VA | ANTHEM BCBS (312 KING STREET) | OTHER | 61459600 | 01 | VA | BLACK LUNG/FECA (STE 3105) | OTHER | 61459602 | 01 | VA | BLACK LUNG/FECA (412 NAMOZINE STR) | OTHER | 61459604 | 01 | VA | BLACK LUNG/FECA (1418 6TH ST) | OTHER | 345604 | 01 | VA | ANTHEM BCBS (800 OAK STREET) | OTHER | 345307 | 01 | VA | ANTHEM, BCBS (1418 6TH STREET) | OTHER | 345606 | 01 | VA | ANTHEM BCBS (412 NAMOZINE STREET) | OTHER | 61459601 | 01 | VA | BLACK LUNG/FECA (312 KING ST) | OTHER | 61459603 | 01 | VA | BLACK LUNG/FECA (1705 3RD ST) | OTHER | 1841479565 | 05 | VA | MEDICAID | 9978134 | 01 | VA | AETNA | OTHER |