Healthcare Provider Details

I. General information

NPI: 1679781314
Provider Name (Legal Business Name): SOUTHSIDE PULMONARY & SLEEP CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 GREENWOOD SPRINGS BLVD
GREENWOOD IN
46143-7975
US

IV. Provider business mailing address

1040 GREENWOOD SPRINGS BLVD
GREENWOOD IN
46143-7975
US

V. Phone/Fax

Practice location:
  • Phone: 317-893-0888
  • Fax: 317-893-0815
Mailing address:
  • Phone: 317-893-0888
  • Fax: 317-893-0815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. TIM HANK WOOLDRIDGE
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 317-893-0888