=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669970067
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHSIDE PEDIATRICS & ADULT CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2018
-----------------------------------------------------
Last Update Date | 06/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1185 MOUNT AETNA RD STE 200
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21740-6832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-513-6300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1185 MOUNT AETNA RD STE 200
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21740-6832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-513-6300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. CHRISTA MARTIN
-----------------------------------------------------
Credential | CRNP
-----------------------------------------------------
Telephone | 240-513-6300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 193525
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------