Healthcare Provider Details

I. General information

NPI: 1841479565
Provider Name (Legal Business Name): CENTRA MEDICAL GROUP SOUTHSIDE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 OAK ST
FARMVILLE VA
23901-1199
US

IV. Provider business mailing address

2010 ATHERHOLT RD
LYNCHBURG VA
24501-1106
US

V. Phone/Fax

Practice location:
  • Phone: 434-200-3656
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM BASS
Title or Position: CFO
Credential:
Phone: 434-392-8811