Healthcare Provider Details

I. General information

NPI: 1073544508
Provider Name (Legal Business Name): SOUTHERN MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E STADIUM
MAGNOLIA AR
71753-2032
US

IV. Provider business mailing address

211 E STADIUM
MAGNOLIA AR
71753-2032
US

V. Phone/Fax

Practice location:
  • Phone: 870-234-5995
  • Fax: 870-234-0278
Mailing address:
  • Phone: 870-234-5995
  • Fax: 870-234-0278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JEAN MORRIS
Title or Position: BILLING
Credential: BILLING
Phone: 870-234-5995