1013544899 NPI number — SOUTHERN NEUROLOGY, PHYSICAL MEDICINE & REHABILITATION, LLC

Table of content: (NPI 1013544899)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013544899 NPI number — SOUTHERN NEUROLOGY, PHYSICAL MEDICINE & REHABILITATION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN NEUROLOGY, PHYSICAL MEDICINE & REHABILITATION, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
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Provider Other Last Name:
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NPI Number Information

NPI Number:
1013544899
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4913 LANES POND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALDOSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31601-1537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-292-2074
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4913 LANES POND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALDOSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31601-1537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-292-2074
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/24/2020

Additional Information

Authorized Official

Authorized Official Last Name:
BUSSEY
Authorized Official First Name:
TOMMY
Authorized Official Middle Name:
KEITH
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
229-292-2074

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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