Southside Primary Care, Inc.

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

License

0102037027 Issued in VA

Legal business name

SOUTHSIDE PRIMARY CARE, INC.

Doing business as

Southside Internal Medicine

Practice address

4103 Lafayette Blvd
Suite 2
Fredericksburg, VA 22408-4274

Phone

(540) 891-5550

NPI assigned

Nov 19, 2009

Organization subpart

No

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

Authorized official

Name

Ashleigh A Raubenolt

Title

Credentialing

Phone

(540) 371-4488

Specialties & licenses 1

Addresses

Other names 1

• Southside Internal Medicine Doing business as

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

{
    "created_epoch": "1258588800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1258588800000",
    "number": "1184952707",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4103 LAFAYETTE BLVD",
            "address_2": "SUITE 2",
            "city": "FREDERICKSBURG",
            "state": "VA",
            "postal_code": "224084274",
            "telephone_number": "540-891-5550"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4103 LAFAYETTE BLVD",
            "address_2": "SUITE 2",
            "city": "FREDERICKSBURG",
            "state": "VA",
            "postal_code": "224084274",
            "telephone_number": "540-891-5550"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHSIDE PRIMARY CARE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-11-19",
        "last_updated": "2009-11-19",
        "status": "A",
        "authorized_official_last_name": "RAUBENOLT",
        "authorized_official_first_name": "ASHLEIGH",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "CREDENTIALING",
        "authorized_official_telephone_number": "540-371-4488"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": "VA",
            "license": "0102037027",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southside Internal Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Elizabeth A. Soukup-Taylor, LCSW, CSAC, CETP
• Soulutions LLC
• Source Fountain Wellness LLC
• Southpointe OBGYN, LLC
• Southside Internal Medicine of Fredericksburg PC
• James Robert Spadoni, M.D.
• Nicquia Spain, DO
• Stephanie J Spangler, MSW
• Brooke Renae Sparks, NP-C
• Ann K Spaulding, PA

• Internal Medicine Physician in Fredericksburg, VA
• Providers in Fredericksburg, VA by specialty
• Internal Medicine Physician in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 19, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.