Healthcare Provider Details

I. General information

NPI: 1770909921
Provider Name (Legal Business Name): SOUTHSIDE MEDICAL MANAGEMENT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 W ATLANTIC ST
SOUTH HILL VA
23970-1906
US

IV. Provider business mailing address

514 W ATLANTIC ST
SOUTH HILL VA
23970-1906
US

V. Phone/Fax

Practice location:
  • Phone: 434-584-2000
  • Fax: 434-447-2240
Mailing address:
  • Phone: 434-584-2000
  • Fax: 434-447-2240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101040317
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number0101040317
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101042014
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110002166
License Number StateVA
# 6
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0024168641
License Number StateVA
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateVA
# 8
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number StateVA

VIII. Authorized Official

Name: GRAHANM H POWERS III
Title or Position: PARTNER
Credential: MD
Phone: 434-584-2000