Healthcare Provider Details

I. General information

NPI: 1003279662
Provider Name (Legal Business Name): JAKE SIDES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PARK BLVD STE 250W
BRISTOL TN
37620-7431
US

IV. Provider business mailing address

1021 W OAKLAND AVE STE 310
JOHNSON CITY TN
37604-2192
US

V. Phone/Fax

Practice location:
  • Phone: 423-844-6620
  • Fax: 423-844-6626
Mailing address:
  • Phone: 423-302-6565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101275797
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number63286
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: