21D2102704 CLIA NUMBER - SOUTH SIDE PEDIATRICS

Laboratory Demographics

CLIA Number: 21D2102704

Facility Name: SOUTH SIDE PEDIATRICS

Facility Address:
1185 MT AETNA ROAD SUITE 200
HAGERSTOWN, MD
ZIP 21740
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Facility Phone Number: 240 513-6300

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1669970067

Taxonomy: 261QP2300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	21D2102704
LAB Type	Practitioner Other
Facility Name	SOUTH SIDE PEDIATRICS
Street	1185 MT AETNA ROAD SUITE 200
City	HAGERSTOWN
State	MD
ZIP	21740
Phone	240 513-6300
CertificateType	4
CertificateEffectiveDate	9/28/2023
CertificateExpirationDate	9/27/2025
FacilityType	Waiver

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