Provider Demographics
NPI:1427322882
Name:SOUTHSIDE OB-GYN PLLC
Entity type:Organization
Organization Name:SOUTHSIDE OB-GYN PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDY
Authorized Official - Middle Name:
Authorized Official - Last Name:AMISIAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-657-2269
Mailing Address - Street 1:1380 NE MIAMI GARDENS DR STE 140B
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179-4744
Mailing Address - Country:US
Mailing Address - Phone:786-657-2269
Mailing Address - Fax:786-955-6972
Practice Address - Street 1:1380 NE MIAMI GARDENS DR STE 140B
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33179-4744
Practice Address - Country:US
Practice Address - Phone:786-657-2269
Practice Address - Fax:786-955-6972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-02
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME108552207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004060500Medicaid