MEDICARE: SOUTHSIDE HEALTH ASSOCIATION

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	207R00000X	Internal Medicine Physician		IL

General Provider Information

NPI Number	:	1922052406
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSIDE HEALTH ASSOCIATION

Provider Business Mailing Address
First Line	:	1701 W MONTEREY AVE
Second Line	:	SUITE 1
City	:	CHICAGO
State	:	IL
Zip	:	60643-4257
Country	:	US
Telephone Number	:	773-233-5850
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 W MONTEREY AVE
Second Line	:	SUITE 1
City	:	CHICAGO
State	:	IL
Zip	:	60643-4257
Country	:	US
Telephone Number	:	773-233-5850
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	WILLIAM A JOHNSON
Credential	:	MD
Telephone Number	:	773-233-5850

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	08/22/2020

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Directions to “SOUTHSIDE HEALTH ASSOCIATION ” Practice Location

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