| Southside Internal Medicine Pc | |
|
804 Commerce Blvd Suite B Riverdale GA 30296-7198 | |
| (770) 997-6644 | |
| (770) 997-6630 |
| Full Name | Southside Internal Medicine Pc |
|---|---|
| Speciality | Clinic/Center |
| Location | 804 Commerce Blvd, Riverdale, Georgia |
| Authorized Official Name and Position | Casimir Okoro (MEDICAL DOCTOR) |
| Authorized Official Contact | 7709976644 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Southside Internal Medicine Pc 7384 Highway 85 Riverdale GA 30274-3453 Ph: (770) 997-6644 | Southside Internal Medicine Pc 804 Commerce Blvd Suite B Riverdale GA 30296-7198 Ph: (770) 997-6644 |
| NPI Number | 1740583194 |
|---|---|
| Provider Enumeration Date | 12/07/2010 |
| Last Update Date | 01/14/2015 |
| Medicare PECOS PAC ID | 5092904144 |
|---|---|
| Medicare Enrollment ID | O20110105001008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1740583194 | NPI | - | NPPES |
| 000544948J | Medicaid | GA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Primary |
| Provider Name | Casimir C Okoro |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1508948563 PECOS PAC ID: 0345439493 Enrollment ID: I20110105001037 |
| Provider Name | Maritess Thomas |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1013461425 PECOS PAC ID: 6406132166 Enrollment ID: I20170411002379 |
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