MEDICARE: SOUTHSIDE MEDICAL TRANSPORATION

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	343900000X	Non-emergency Medical Transport (VAN)	S09JXJ	TX

General Provider Information

NPI Number	:	1821252909
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSIDE MEDICAL TRANSPORATION

Provider Business Mailing Address
First Line	:	6829 ALMEDA GENOA RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77075-2803
Country	:	US
Telephone Number	:	713-991-5518
Fax Number	:	713-991-5357

Provider Business Practice Location Address
First Line	:	6829 ALMEDA GENOA RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77075-2803
Country	:	US
Telephone Number	:	713-991-5518
Fax Number	:	713-991-5357

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. DELORES MAXINE JACKSON
Credential	:
Telephone Number	:	713-991-5518

Provider Enumeration Date	:	07/17/2008
Last Update Date	:	07/17/2008

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Directions to “SOUTHSIDE MEDICAL TRANSPORATION ” Practice Location

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