NPIMap

Organization Active NPI

Southside Dermatology PLLC

  • Dermatology Physician
  • Broken Arrow, OK
National Provider Identifier
1073263380
Registry record updated Mar 28, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
SOUTHSIDE DERMATOLOGY PLLC
Practice address
3300 S Aspen Ave Ste a
Broken Arrow, OK 74012-7501
Phone
(918) 760-0700
NPI assigned
Mar 28, 2022
Last updated
Mar 28, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 28, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Alison FischerNPI 1225266307
Title
Owner
Phone
(918) 760-0700

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207N00000X Primary

Addresses

Primary practice location

3300 S Aspen Ave Ste a
Broken Arrow, OK 74012-7501

Mailing address

6966 S Utica Ave Ste 225
Tulsa, OK 74136-3903
Phone (918) 492-6333

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OK

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180802002933 OK Part B Supplier - Clinic/Group Practice 9234487554 Receives reassigned benefits from 14 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Muskogee, OK; Tulsa, OK; Broken Arrow, OK

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

7320 S Yale Ave
Tulsa, OK 74136
Phone (918) 760-0700

Interoperability endpoints

  • FHIR API: https://app.meldrx.com/api/fhir/ez_00426

Practitioners & affiliated clinicians

Practitioners 15

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1648425600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1648425600000",
    "number": "1073263380",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6966 S UTICA AVE STE 225",
            "city": "TULSA",
            "state": "OK",
            "postal_code": "741363903",
            "telephone_number": "918-492-6333",
            "fax_number": "918-493-9405"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3300 S ASPEN AVE STE A",
            "city": "BROKEN ARROW",
            "state": "OK",
            "postal_code": "740127501",
            "telephone_number": "918-760-0700"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHSIDE DERMATOLOGY PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-03-28",
        "last_updated": "2022-03-28",
        "certification_date": "2022-03-28",
        "status": "A",
        "authorized_official_last_name": "FISCHER",
        "authorized_official_first_name": "ALISON",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "918-760-0700"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Broken Arrow, OK

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 28, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.