Provider Demographics
NPI:1366525040
Name:SOUTHSIDE PEDIATRICS, P.C.
Entity type:Organization
Organization Name:SOUTHSIDE PEDIATRICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERESITA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIONISIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-392-9438
Mailing Address - Street 1:502 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-1222
Mailing Address - Country:US
Mailing Address - Phone:434-392-9438
Mailing Address - Fax:434-392-7630
Practice Address - Street 1:502 BEECH ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-1222
Practice Address - Country:US
Practice Address - Phone:434-392-9438
Practice Address - Fax:434-392-7630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035421173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010018579Medicaid
VA081150OtherDR D ANTHEM#
VA006702767Medicaid
VA99161OtherOPTIMA # DR D
VA99161OtherOPTIMA # DR D