Southside Medical Clinic

Primary specialty

Clinic/CenterTaxonomy code 261Q00000X

License

ME0043239 Issued in FL

Legal business name

SOUTHSIDE MEDICAL CLINIC

Practice address

1707 E Edgewood Dr
Lakeland, FL 33803-3470

Phone

(863) 688-9219

Fax

(863) 687-4863

NPI assigned

Feb 21, 2013

Last updated

Feb 21, 2013By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Dr. Roger David Suares, M.D.

Title

Medical Director

Phone

(863) 688-9219

Specialties & licenses 1

Addresses

Locations

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

{
    "created_epoch": "1361404800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1361404800000",
    "number": "1356681845",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1707 E EDGEWOOD DR",
            "city": "LAKELAND",
            "state": "FL",
            "postal_code": "338033470",
            "telephone_number": "863-688-9219",
            "fax_number": "863-687-4863"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1707 E EDGEWOOD DR",
            "city": "LAKELAND",
            "state": "FL",
            "postal_code": "338033470",
            "telephone_number": "863-688-9219",
            "fax_number": "863-687-4863"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHSIDE MEDICAL CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-02-21",
        "last_updated": "2013-02-21",
        "status": "A",
        "authorized_official_last_name": "SUARES",
        "authorized_official_first_name": "ROGER",
        "authorized_official_middle_name": "DAVID",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "863-688-9219",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "FL",
            "license": "ME0043239",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Clinic/Center in Lakeland, FL
• Providers in Lakeland, FL by specialty
• Clinic/Center in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 21, 2013; 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.