# CENTRA MEDICAL GROUP SOUTHSIDE, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1841479565
- **Authorized official:** WILLIAM BASS (CFO)
- **Authorized official phone:** (434) 392-8811

## Contact information

- **Practice address:** 800 OAK ST, FARMVILLE, VA 23901-1199
- **Practice address phone:** (434) 200-3656
- **Mailing address:** 2010 ATHERHOLT RD, LYNCHBURG, VA 24501-1106

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 207R00000X | Internal Medicine Physician | — | NULL | — |
| 207R00000X | Internal Medicine Physician | — | — | — |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | — | NULL | — |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | — | — | — |
| 2084N0400X | Neurology Physician | — | NULL | — |
| 2084N0400X | Neurology Physician | — | — | — |
| 208600000X | Surgery Physician | — | NULL | — |
| 208600000X | Surgery Physician | — | — | — |

## Other

- **Enumeration date:** 10/30/2007
- **Last updated:** 08/07/2014

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1841479565 | — | VA |
| 01 | — | 345307 | ANTHEM, BCBS (1418 6TH STREET) | VA |
| 01 | — | 345604 | ANTHEM BCBS (800 OAK STREET) | VA |
| 01 | — | 345606 | ANTHEM BCBS (412 NAMOZINE STREET) | VA |
| 01 | — | 345608 | ANTHEM BCBS (312 KING STREET) | VA |
| 01 | — | 61459600 | BLACK LUNG/FECA (STE 3105) | VA |
| 01 | — | 61459601 | BLACK LUNG/FECA (312 KING ST) | VA |
| 01 | — | 61459602 | BLACK LUNG/FECA (412 NAMOZINE STR) | VA |
| 01 | — | 61459603 | BLACK LUNG/FECA (1705 3RD ST) | VA |
| 01 | — | 61459604 | BLACK LUNG/FECA (1418 6TH ST) | VA |
| 01 | — | 9978134 | AETNA | VA |