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General NPI Number Information
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NPI Number | 1740583194
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Entity Type | Organization
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Legal Business Name | SOUTHSIDE INTERNAL MEDICINE PC
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Dates
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Enumeration Date | 12/07/2010
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Last Update Date | 01/14/2015
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Provider Practice Location Address
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Address Line | 804 COMMERCE BLVD SUITE B
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City | RIVERDALE
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State | GA
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Zip | 30296-7198
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Country | US
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Telephone | 770-997-6644
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Fax | 770-997-6630
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Provider Business Mailing Address
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Address Line | 7384 HIGHWAY 85
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City | RIVERDALE
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State | GA
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Zip | 30274-3453
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Country | US
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Telephone | 770-997-6644
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Fax | 770-997-6630
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Authorized Official
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Title or Position | MEDICAL DOCTOR
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Name | DR. CASIMIR OKORO
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Credential | M.D
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Telephone | 770-997-6644
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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