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General NPI Number Information
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NPI Number | 1972782019
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Entity Type | Organization
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Legal Business Name | SOUTHSIDE MEDICAL CENTER PA
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Dates
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Enumeration Date | 10/25/2007
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Last Update Date | 10/25/2007
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Provider Practice Location Address
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Address Line | 3921 S HIGHWAY 14 STE A
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City | GREENVILLE
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State | SC
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Zip | 29615-6138
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Country | US
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Telephone | 864-288-2006
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Fax | 864-288-1678
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Provider Business Mailing Address
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Address Line | 3921 S HIGHWAY 14 STE A
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City | GREENVILLE
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State | SC
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Zip | 29615-6138
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Country | US
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Telephone | 864-288-2006
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Fax | 864-288-1678
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Authorized Official
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Title or Position | OWNER
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Name | DR. THAER JOUDEH
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Credential | MD
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Telephone | 864-288-2006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 21696
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License Number State | SC
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