Provider Demographics
NPI:1447376140
Name:SOUTHSIDE ORTHOPAEDICS P.C.
Entity type:Organization
Organization Name:SOUTHSIDE ORTHOPAEDICS P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:REGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-361-3930
Mailing Address - Street 1:11757 SOUTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1084
Mailing Address - Country:US
Mailing Address - Phone:708-361-3930
Mailing Address - Fax:708-361-7969
Practice Address - Street 1:11757 SOUTHWEST HWY
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1015
Practice Address - Country:US
Practice Address - Phone:708-361-3930
Practice Address - Fax:708-361-7969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060.002144 036.04481174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01633518OtherBC/BS
IL0364580001Medicare NSC