Healthcare Provider Details

I. General information

NPI: 1508648445
Provider Name (Legal Business Name): SOUTHERN INJURY SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 BROAD ST SE STE A
GAINESVILLE GA
30501-3718
US

IV. Provider business mailing address

601 BROAD ST SE STE A
GAINESVILLE GA
30501-3718
US

V. Phone/Fax

Practice location:
  • Phone: 678-971-4167
  • Fax: 833-989-2501
Mailing address:
  • Phone: 678-971-4167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ANKUR PATEL
Title or Position: OWNER
Credential: DO
Phone: 205-422-5189