Healthcare Provider Details

I. General information

NPI: 1912480070
Provider Name (Legal Business Name): SOG SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2018
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 S GLOSTER ST STE B
TUPELO MS
38801-6535
US

IV. Provider business mailing address

1211 S GLOSTER ST STE B
TUPELO MS
38801-6548
US

V. Phone/Fax

Practice location:
  • Phone: 662-432-1490
  • Fax:
Mailing address:
  • Phone: 662-432-1490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: THOMAS LUSTER
Title or Position: CEO
Credential:
Phone: 662-767-4200