04D1071452 CLIA NUMBER - SOUTHSIDE MEDICAL CLINIC

Laboratory Demographics

  • CLIA Code: 04D1071452
  • Facility Name: SOUTHSIDE MEDICAL CLINIC
  • Facility Address: 623 SOUTH 21ST STREET
    FORT SMITH, AR
    ZIP 72901
  • Facility Phone: 479 441-1500
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: THUYLINH H. PHAM
  • NPI Number: 1194937235
  • Taxonomy: 207R00000X - Internal Medicine

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CLIA Record

Field Name Field Value
CLIA Number 04D1071452
LAB Type Physician Office
Facility Name SOUTHSIDE MEDICAL CLINIC
Street 623 SOUTH 21ST STREET
City FORT SMITH
State AR
ZIP 72901
Phone 479 441-1500
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 7/26/2023
Certificate Expiration Date 7/25/2025
Facility Type Physician Office
Lab Director THUYLINH H. PHAM

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This page was last updated on: 3/20/2025