Healthcare Provider Details

I. General information

NPI: 1578680872
Provider Name (Legal Business Name): SOUTHSIDE COMMUNITY HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5640 MEMORIAL AVE N SUITE B
STILLWATER MN
55082-2166
US

IV. Provider business mailing address

4243 4TH AVE S
MINNEAPOLIS MN
55409-2113
US

V. Phone/Fax

Practice location:
  • Phone: 651-430-1880
  • Fax: 651-430-1323
Mailing address:
  • Phone: 612-822-9030
  • Fax: 612-821-2818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM HENRY TENDLE JR.
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 612-821-2800