Healthcare Provider Details

I. General information

NPI: 1639326994
Provider Name (Legal Business Name): SOUTHERN SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 06/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 VERNON RD SUITE C
LAGRANGE GA
30240-3871
US

IV. Provider business mailing address

1805 VERNON RD SUITE C
LAGRANGE GA
30240-3871
US

V. Phone/Fax

Practice location:
  • Phone: 706-812-9902
  • Fax: 706-812-0802
Mailing address:
  • Phone: 706-812-9902
  • Fax: 706-812-0802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. PAT THOMPSON
Title or Position: BOM
Credential:
Phone: 706-812-9902