1619398328 NPI number — SOUTHERN SURGICAL PROVIDERS, P.C.

Table of content: (NPI 1619398328)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619398328 NPI number — SOUTHERN SURGICAL PROVIDERS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN SURGICAL PROVIDERS, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619398328
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7120 HODGSON MEMORIAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31406-2532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-754-0382
Provider Business Mailing Address Fax Number:
912-754-0225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
459 HIGHWAY 119 S
Provider Second Line Business Practice Location Address:
PHYSICIAN CENTER # 2
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31329-3021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-352-4490
Provider Business Practice Location Address Fax Number:
912-352-4845
Provider Enumeration Date:
12/23/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WYNN
Authorized Official First Name:
R.
Authorized Official Middle Name:
ALEXANDER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
912-754-0382

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  56939 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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