NPIMap

Organization Active NPI

Southside Community Health Services, Inc.

  • Family Medicine Physician
  • Stillwater, MN
National Provider Identifier
1578680872
Registry record updated Apr 30, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
SOUTHSIDE COMMUNITY HEALTH SERVICES, INC.
Practice address
5640 Memorial Ave N
Suite B
Stillwater, MN 55082-2166
Phone
(651) 430-1880
Fax
(651) 430-1323
NPI assigned
Mar 23, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 30, 2014

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

Authorized official

Name
William Henry Tendle Jr.
Title
Executive Director
Phone
(612) 821-2800

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

5640 Memorial Ave N
Suite B
Stillwater, MN 55082-2166

Mailing address

4243 4TH Ave S
Minneapolis, MN 55409-2113
Phone (612) 822-9030

Other identifiers 1

IdentifierTypeStateIssuer
943170500MedicaidMN

Other names 1

  • St. Croix Family Medical Clinic Other name

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1174608000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1398816000000",
    "number": "1578680872",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4243 4TH AVE S",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554092113",
            "telephone_number": "612-822-9030",
            "fax_number": "612-821-2818"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5640 MEMORIAL AVE N",
            "address_2": "SUITE B",
            "city": "STILLWATER",
            "state": "MN",
            "postal_code": "550822166",
            "telephone_number": "651-430-1880",
            "fax_number": "651-430-1323"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHSIDE COMMUNITY HEALTH SERVICES, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-23",
        "last_updated": "2014-04-30",
        "status": "A",
        "authorized_official_last_name": "TENDLE",
        "authorized_official_first_name": "WILLIAM",
        "authorized_official_middle_name": "HENRY",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "612-821-2800",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "943170500",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "St. Croix Family Medical Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Stillwater, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 30, 2014; 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.