Healthcare Provider Details

I. General information

NPI: 1114146677
Provider Name (Legal Business Name): SOUTHERN HOSPITAL PHYSICIANS,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 08/05/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 BLACKLAND CT E
MARIETTA GA
30067
US

IV. Provider business mailing address

PO BOX 54424
ATLANTA GA
30308-0424
US

V. Phone/Fax

Practice location:
  • Phone: 404-313-0515
  • Fax: 678-540-5473
Mailing address:
  • Phone: 770-458-1594
  • Fax: 770-458-1596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number047899
License Number StateGA

VIII. Authorized Official

Name: KENNETH R. WARNER
Title or Position: MANAGER
Credential:
Phone: 404-313-0515