MEDICARE: SOUTHSIDE PHYSICIANS FOR WOMEN, LLC

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	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1811193055
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSIDE PHYSICIANS FOR WOMEN, LLC

Provider Business Mailing Address
First Line	:	510 S SYCAMORE ST
Second Line	:	SUITE A & B
City	:	PETERSBURG
State	:	VA
Zip	:	23803-5044
Country	:	US
Telephone Number	:	804-862-3455
Fax Number	:	804-862-1439

Provider Business Practice Location Address
First Line	:	510 S SYCAMORE ST
Second Line	:	SUITE A & B
City	:	PETERSBURG
State	:	VA
Zip	:	23803-5044
Country	:	US
Telephone Number	:	804-862-3455
Fax Number	:	804-862-1439

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KRISHNA RAO KUDARAVALLI
Credential	:	M.D.
Telephone Number	:	804-862-3455

Provider Enumeration Date	:	06/25/2007
Last Update Date	:	11/13/2007

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