Healthcare Provider Details

I. General information

NPI: 1760410385
Provider Name (Legal Business Name): HOSPITAL PHYSICIAN SERVICES - SOUTHEAST PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 W SPRING ST
MONROE GA
30655-3202
US

IV. Provider business mailing address

1643 NW 136TH AVE STE 100
SUNRISE FL
33323-2857
US

V. Phone/Fax

Practice location:
  • Phone: 770-267-8461
  • Fax:
Mailing address:
  • Phone: 800-424-3672
  • Fax: 954-377-3042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TONYA LYNN SCANLAN
Title or Position: PE DIRECTOR
Credential:
Phone: 954-377-2954