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General NPI Number Information
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NPI Number | 1497823314
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Entity Type | Organization
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Legal Business Name | SOUTHSIDE MEDICAL CLINIC INC
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Dates
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Enumeration Date | 11/30/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 913 SOUTH 10TH STREET
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City | MOUNT VERNON
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State | IL
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Zip | 62864-5313
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Country | US
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Telephone | 618-242-2745
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Fax | 618-242-2766
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Provider Business Mailing Address
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Address Line | 913 SOUTH 10TH STREET
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City | MOUNT VERNON
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State | IL
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Zip | 62864-5313
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Country | US
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Telephone | 618-242-2745
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Fax | 618-242-2766
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | BRUCE WAYNE MELVIN
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Credential |
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Telephone | 618-242-2745
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number | 001
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License Number State | IL
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