Healthcare Provider Details

I. General information

NPI: 1568413656
Provider Name (Legal Business Name): SOUTHSIDE MEDICAL SUPPLY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 S. CLINTON AVE. STE 320
ROCHESTER NY
14618-5719
US

IV. Provider business mailing address

1900 S. CLINTON AVE STE 320 ROCH. NY 14618
ROCHESTER NY
14618-5719
US

V. Phone/Fax

Practice location:
  • Phone: 585-271-7141
  • Fax: 585-419-6163
Mailing address:
  • Phone: 585-271-7141
  • Fax: 585-419-6163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MS. KELLY A DOLES
Title or Position: BILLING MANAGER
Credential:
Phone: 585-770-2281