Southside Medical Clinic Inc

Primary specialty

Rural Health Clinic/CenterTaxonomy code 261QR1300X

License

001 Issued in IL

Legal business name

SOUTHSIDE MEDICAL CLINIC INC

Practice address

913 South 10TH Street
Mount Vernon, IL 62864-5313

Phone

(618) 242-2745

Fax

(618) 242-2766

NPI assigned

Nov 30, 2006

Organization subpart

No

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

Authorized official

Name

Bruce Wayne Melvin

Title

Executive Director

Phone

(618) 242-2745

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Locations

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

{
    "created_epoch": "1164844800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1497823314",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "913 SOUTH 10TH STREET",
            "city": "MOUNT VERNON",
            "state": "IL",
            "postal_code": "628645313",
            "telephone_number": "618-242-2745",
            "fax_number": "618-242-2766"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "913 SOUTH 10TH STREET",
            "city": "MOUNT VERNON",
            "state": "IL",
            "postal_code": "628645313",
            "telephone_number": "618-242-2745",
            "fax_number": "618-242-2766"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHSIDE MEDICAL CLINIC INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-30",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "MELVIN",
        "authorized_official_first_name": "BRUCE",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "618-242-2745"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "IL",
            "license": "001",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Claudia Rae Spotanski, PA-C

• Rural Health Clinic/Center in Mount Vernon, IL
• Providers in Mount Vernon, IL by specialty
• Rural Health Clinic/Center in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; OIG LEIE.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.