Provider Demographics
NPI:1194937235
Name:SOUTHSIDE MEDICAL CLINIC
Entity type:Organization
Organization Name:SOUTHSIDE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:THUYLINH
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-424-5079
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-0310
Mailing Address - Country:US
Mailing Address - Phone:870-424-0899
Mailing Address - Fax:870-424-8455
Practice Address - Street 1:623 S 21ST ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-3914
Practice Address - Country:US
Practice Address - Phone:479-441-1500
Practice Address - Fax:479-441-1502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1751207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty