Healthcare Provider Details

I. General information

NPI: 1538529631
Provider Name (Legal Business Name): SOUTHERN ALLERGY & ASTHMA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 03/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 TOWNE CENTER BLVD BUILDING 500 SUITE 305
POOLER GA
31322-4052
US

IV. Provider business mailing address

PO BOX 15119
SAVANNAH GA
31416-1819
US

V. Phone/Fax

Practice location:
  • Phone: 912-721-5150
  • Fax: 912-629-0468
Mailing address:
  • Phone: 912-721-5150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number43360
License Number StateGA

VIII. Authorized Official

Name: APRIL R YOUNG
Title or Position: MANAGER
Credential:
Phone: 912-721-5150