Provider Demographics
NPI:1194803338
Name:SOUTHSIDE HEAD N NECK SURGERY PROFESSIONAL CORP
Entity type:Organization
Organization Name:SOUTHSIDE HEAD N NECK SURGERY PROFESSIONAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CANGCUESTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-337-1110
Mailing Address - Street 1:930 SOUTH AVE.
Mailing Address - Street 2:SUITE 4B
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834
Mailing Address - Country:US
Mailing Address - Phone:804-504-0530
Mailing Address - Fax:804-504-0532
Practice Address - Street 1:930 SOUTH AVE.
Practice Address - Street 2:SUITE 4B
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834
Practice Address - Country:US
Practice Address - Phone:804-504-0530
Practice Address - Fax:804-504-0532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036702207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA040009007OtherMEDICARE RAILROAD
VAP00002082OtherMEDICARE RAILROAD
VA006555055OtherMEDICARE RAILROAD
VAP00002088OtherMEDICARE RAILROAD
VAP00002082OtherMEDICARE RAILROAD
C03320Medicare PIN
VA040009007OtherMEDICARE RAILROAD