1316746530 NPI number — PHILIP SOUTHERN APRN, PMHNP-BC

Table of content: PHILIP SOUTHERN APRN, PMHNP-BC (NPI 1316746530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316746530 NPI number — PHILIP SOUTHERN APRN, PMHNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOUTHERN
Provider First Name:
PHILIP
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN, PMHNP-BC
Provider Gender Code:
M

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:
1316746530
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3626 WILLIAMS DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GEORGETOWN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78628-4092
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-374-5066
Provider Business Mailing Address Fax Number:
303-200-8356

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3626 WILLIAMS DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78628-4092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-374-5066
Provider Business Practice Location Address Fax Number:
512-233-2751
Provider Enumeration Date:
03/10/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  1190401 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com