Healthcare Provider Details

I. General information

NPI: 1619068673
Provider Name (Legal Business Name): SOUTHSIDE SURGICAL SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 EXECUTIVE DR STE B
DANVILLE VA
24541-4160
US

IV. Provider business mailing address

159 EXECUTIVE DR STE B
DANVILLE VA
24541-4160
US

V. Phone/Fax

Practice location:
  • Phone: 434-792-5964
  • Fax: 434-792-5971
Mailing address:
  • Phone: 434-792-5964
  • Fax: 434-792-5971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101232606
License Number StateVA

VIII. Authorized Official

Name: MRS. JOAN C MARTIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 434-792-5964