Healthcare Provider Details

I. General information

NPI: 1477869337
Provider Name (Legal Business Name): KIDMED SOUTHSIDE PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2010
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5021 CRAIG RATH BLVD BLDG IV
MIDLOTHIAN VA
23112-6243
US

IV. Provider business mailing address

4687 POUNCEY TRACT RD
GLEN ALLEN VA
23059-5802
US

V. Phone/Fax

Practice location:
  • Phone: 804-422-5437
  • Fax: 804-422-5438
Mailing address:
  • Phone: 804-422-5437
  • Fax: 804-422-5438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK ADAM FLANZENBAUM
Title or Position: PRESIDENT/MANAGING PARTNER
Credential: M.D.
Phone: 804-592-5437