Provider Demographics
NPI:1154577922
Name:SOUTHSIDE MEDICAL ASSOICATES LLC
Entity type:Organization
Organization Name:SOUTHSIDE MEDICAL ASSOICATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ABRAMOWITTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-556-6620
Mailing Address - Street 1:1950 OLD GALLOWS RD. # 220
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182
Mailing Address - Country:US
Mailing Address - Phone:703-556-6620
Mailing Address - Fax:703-556-6625
Practice Address - Street 1:4203 BELFORT ROAD
Practice Address - Street 2:
Practice Address - City:JAKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216
Practice Address - Country:US
Practice Address - Phone:703-556-6620
Practice Address - Fax:703-556-6625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8120207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty