1750775789 NPI number — SOUTHERN INTERNAL MEDICINE CRITICAL CARE ASSOCIATES, LLC

Table of content: MORGAN POPHAM M.S. (NPI 1093262669)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750775789 NPI number — SOUTHERN INTERNAL MEDICINE CRITICAL CARE ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN INTERNAL MEDICINE CRITICAL CARE ASSOCIATES, LLC
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:
1750775789
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6750
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30916-6750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-504-4651
Provider Business Mailing Address Fax Number:
706-504-4639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3614 J DEWEY GRAY CIR
Provider Second Line Business Practice Location Address:
BULDING B
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30909-6602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-504-4651
Provider Business Practice Location Address Fax Number:
706-504-4639
Provider Enumeration Date:
03/27/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SHAVER
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
706-339-5092

Provider Taxonomy Codes

  • Taxonomy code: 207RC0200X , with the licence number:  042430 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RP1001X , with the licence number: 042430 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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