Provider Demographics
NPI:1316150006
Name:SOUTHSIDE OB-GYN, INC.
Entity type:Organization
Organization Name:SOUTHSIDE OB-GYN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:TOMLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-732-0136
Mailing Address - Street 1:600 S SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-5815
Mailing Address - Country:US
Mailing Address - Phone:804-732-0136
Mailing Address - Fax:804-861-9661
Practice Address - Street 1:600 S SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-5815
Practice Address - Country:US
Practice Address - Phone:804-732-0136
Practice Address - Fax:804-861-9661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101029081174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA213198OtherMDIPA OPTIMUM CHOICE
VA212033OtherCIGNA
VA070725OtherANTHEM
VA070725OtherANTHEM
VA212033OtherCIGNA
VAC05445Medicare PIN
VAB09219Medicare UPIN