MEDICARE: PULMONARY ASSOCIATES OF SOUTHSIDE VIRGINIA, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265436117
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PULMONARY ASSOCIATES OF SOUTHSIDE VIRGINIA, INC

Provider Business Mailing Address
First Line	:	2210 WILBORN AVENUE
Second Line	:
City	:	SOUTH BOSTON
State	:	VA
Zip	:	24592
Country	:	US
Telephone Number	:	434-575-5864
Fax Number	:	434-575-8929

Provider Business Practice Location Address
First Line	:	2210 WILBORN AVENUE
Second Line	:
City	:	SOUTH BOSTON
State	:	VA
Zip	:	24592
Country	:	US
Telephone Number	:	434-575-5864
Fax Number	:	434-575-8929

Authorized Official
Title or Position	:	SECRETARY
Name	:	ANNETTE W HARDY
Credential	:
Telephone Number	:	434-575-5864

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	11/15/2010

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