Healthcare Provider Details

I. General information

NPI: 1245098185
Provider Name (Legal Business Name): SOUTHERN PHYSICIANS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2024
Last Update Date: 03/18/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 PASADENA AVE S STE 1E
SOUTH PASADENA FL
33707-4555
US

IV. Provider business mailing address

7045 75TH ST N
PINELLAS PARK FL
33781-3748
US

V. Phone/Fax

Practice location:
  • Phone: 919-349-1232
  • Fax: 727-677-9333
Mailing address:
  • Phone: 919-349-1232
  • Fax: 727-677-9333

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 Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: BRYAN FINK
Title or Position: PRESIDENT
Credential: DO
Phone: 727-677-9333