MEDICARE: ROADSIDE MEDICAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1457665382
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROADSIDE MEDICAL, LLC

Provider Business Mailing Address
First Line	:	8466 LOCKWOOD RIDGE RD
Second Line	:	#248
City	:	SARASOTA
State	:	FL
Zip	:	34243-2951
Country	:	US
Telephone Number	:	941-225-2520
Fax Number	:	888-860-8609

Provider Business Practice Location Address
First Line	:	699 STATE ROUTE 203
Second Line	:	SUITE 1
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62201-1608
Country	:	US
Telephone Number	:	941-225-2520
Fax Number	:	888-860-8609

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	JONATHON WITHERSPOON
Credential	:
Telephone Number	:	941-225-2520

Provider Enumeration Date	:	08/03/2010
Last Update Date	:	08/03/2010

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Directions to “ROADSIDE MEDICAL, LLC ” Practice Location

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