Healthcare Provider Details

I. General information

NPI: 1407024557
Provider Name (Legal Business Name): SOUTHSIDE OB/GYN, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9390 FORD AVE SUITE 4
RICHMOND HILL GA
31324-6421
US

IV. Provider business mailing address

PO BOX 1117
RICHMOND HILL GA
31324-1117
US

V. Phone/Fax

Practice location:
  • Phone: 912-756-3404
  • Fax: 912-756-6352
Mailing address:
  • Phone: 912-756-3404
  • Fax: 912-756-2156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: FRANCISCO A. DUENO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 912-656-3533