Organization
CENTRA MEDICAL GROUP SOUTHSIDE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
WILLIAM BASS (CFO)
(434) 392-8811
Entity
Organization
Contact information
Practice address
800 OAK ST, FARMVILLE, VA 23901-1199
(434) 200-3656
Mailing address
2010 ATHERHOLT RD, LYNCHBURG, VA 24501-1106
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
207R00000X
Internal Medicine Physician
—
—
207RE0101X
Endocrinology, Diabetes & Metabolism Physician
—
—
2084N0400X
Neurology Physician
—
—
208600000X
Surgery Physician
—
—
Other
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
Enumeration date
10/30/2007
Last updated
08/07/2014
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