1912188624 NPI number — SOUTHERN INTERNAL MEDICINE PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912188624 NPI number — SOUTHERN INTERNAL MEDICINE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN INTERNAL MEDICINE PLLC
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:
1912188624
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7896 BRIARWOOD CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLEN SAINT MARY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32040-4706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-521-5388
Provider Business Mailing Address Fax Number:
904-259-7845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
404 NW HALL OF FAME DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32055-4833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-754-2433
Provider Business Practice Location Address Fax Number:
386-754-2586
Provider Enumeration Date:
11/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STRAUSS
Authorized Official First Name:
GUY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
904-521-5388

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  OS4706 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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