11D0980346 CLIA NUMBER - SOUTHSIDE INTERNAL MEDICINE PC

Laboratory Demographics

CLIA Number: 11D0980346

Facility Name: SOUTHSIDE INTERNAL MEDICINE PC

Facility Address:
7384 HIGHWAY 85
RIVERDALE, GA
ZIP 30274
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Facility Phone Number: 770 997-6644

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1740583194

Taxonomy: 261QP2300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	11D0980346
LAB Type	Physician Office
Facility Name	SOUTHSIDE INTERNAL MEDICINE PC
Street	7384 HIGHWAY 85
City	RIVERDALE
State	GA
ZIP	30274
Phone	770 997-6644
CertificateType	4
CertificateEffectiveDate	11/17/2022
CertificateExpirationDate	11/16/2024
FacilityType	Waiver

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This page was last updated on: 4/23/2024