Healthcare Provider Details

I. General information

NPI: 1841815826
Provider Name (Legal Business Name): SOUTHERN MEDICINE PRIMARY & URGENT CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 OHIO AVE N
LIVE OAK FL
32064-4868
US

IV. Provider business mailing address

PO BOX 6006
LIVE OAK FL
32064-6006
US

V. Phone/Fax

Practice location:
  • Phone: 386-209-0638
  • Fax: 386-219-0470
Mailing address:
  • Phone:
  • Fax:

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 Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE MORRIS
Title or Position: PRESIDENT
Credential: APRN
Phone: 386-209-0638