Healthcare Provider Details

I. General information

NPI: 1649463431
Provider Name (Legal Business Name): SOUTHSIDE FAMILY MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 HIGHWAY 77
SOUTHSIDE AL
35907-0100
US

IV. Provider business mailing address

1602 HIGHWAY 77
SOUTHSIDE AL
35907-0100
US

V. Phone/Fax

Practice location:
  • Phone: 256-442-7423
  • Fax: 256-442-6762
Mailing address:
  • Phone: 256-442-7423
  • Fax: 256-442-6762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0920
License Number StateAL

VIII. Authorized Official

Name: DR. LISA A FLORENCE
Title or Position: VICE PRESIDENT
Credential: D.O.
Phone: 256-442-7423