Healthcare Provider Details

I. General information

NPI: 1922052406
Provider Name (Legal Business Name): SOUTHSIDE HEALTH ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W MONTEREY AVE SUITE 1
CHICAGO IL
60643-4257
US

IV. Provider business mailing address

1701 W MONTEREY AVE SUITE 1
CHICAGO IL
60643-4257
US

V. Phone/Fax

Practice location:
  • Phone: 773-233-5850
  • Fax:
Mailing address:
  • Phone: 773-233-5850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: WILLIAM A JOHNSON
Title or Position: CEO
Credential: MD
Phone: 773-233-5850