NPIMap

Organization Active NPI

Southside Dermatology PLLC

  • Dermatology Physician
  • Tulsa, OK
National Provider Identifier
1750877072
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
720 W 71St St
Tulsa, OK 74132-7413
Phone
(918) 760-0700
Fax
(918) 628-0700
NPI assigned
Jul 10, 2018
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
Robert Fischer, MDNPI 1023378759
Title
President
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 Physician 207N00000X NU Primary

Addresses

Primary practice location

720 W 71St St
Tulsa, OK 74132-7413

Mailing address

6966 S Utica Ave Ste 225
Tulsa, OK 74136-3903
Phone (918) 760-0700

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
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.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
37D2157238Southside Dermatology, PLLC720 W 71St Street S, Tulsa, OK 74132ComplianceApr 22, 2027

National Provider Directory

National Provider Directory

Locations

5801 E 41st St
Ste 200
Tulsa, OK 74135
Phone (918) 293-9966

720 W 71st St
Tulsa, OK 74132
Phone (918) 760-0700

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": "1531180800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1648425600000",
    "number": "1750877072",
    "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": "918-760-0700"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "720 W 71ST ST",
            "city": "TULSA",
            "state": "OK",
            "postal_code": "741327413",
            "telephone_number": "918-760-0700",
            "fax_number": "918-628-0700"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHSIDE DERMATOLOGY PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-07-10",
        "last_updated": "2022-03-28",
        "certification_date": "2022-03-28",
        "status": "A",
        "authorized_official_last_name": "FISCHER",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "918-760-0700",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Tulsa, 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.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.