MEDICARE: SOUTHSIDE MEDICAL SUPPLY, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	335E00000X	Prosthetic/Orthotic Supplier
2	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)
3	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	182719GD	OTHER	NY	PREFERRED CARE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	7273762	OTHER	NY	AETNA HEALTH, INC
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	P0170059SS	OTHER	NY	EXCELLUS BLUE CROSS

General Provider Information

NPI Number	:	1568413656
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSIDE MEDICAL SUPPLY, LLC

Provider Business Mailing Address
First Line	:	1900 S. CLINTON AVE STE 320 ROCH. NY 14618
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14618-5719
Country	:	US
Telephone Number	:	585-271-7141
Fax Number	:	585-419-6163

Provider Business Practice Location Address
First Line	:	1900 S. CLINTON AVE. STE 320
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14618-5719
Country	:	US
Telephone Number	:	585-271-7141
Fax Number	:	585-419-6163

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	MS. KELLY A DOLES
Credential	:
Telephone Number	:	585-770-2281

Provider Enumeration Date	:	05/13/2006
Last Update Date	:	11/25/2014

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