Healthcare Provider Details

I. General information

NPI: 1982426243
Provider Name (Legal Business Name): SOUTHERN SPECIALTY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 LIBERTY RD
FLOWOOD MS
39232-9000
US

IV. Provider business mailing address

803 LIBERTY RD
FLOWOOD MS
39232-9000
US

V. Phone/Fax

Practice location:
  • Phone: 601-714-1967
  • Fax: 601-714-1966
Mailing address:
  • Phone: 601-714-1967
  • Fax: 601-714-1966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080B0002X
TaxonomyPediatric Obesity Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SHARON PENNINGTON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MD
Phone: 601-985-8296