Healthcare Provider Details

I. General information

NPI: 1013661917
Provider Name (Legal Business Name): SOUTHSIDE SPECTRUM PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5320 PROVIDENCE RD STE 100
VIRGINIA BEACH VA
23464-4122
US

IV. Provider business mailing address

5320 PROVIDENCE RD STE 100
VIRGINIA BEACH VA
23464-4122
US

V. Phone/Fax

Practice location:
  • Phone: 757-451-5000
  • Fax:
Mailing address:
  • Phone: 757-937-3029
  • Fax: 757-937-8290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: TAMBRA HOLLINGSWORTH
Title or Position: OWNER
Credential: NP
Phone: 757-937-3029