Healthcare Provider Details

I. General information

NPI: 1699859355
Provider Name (Legal Business Name): SOUTHERN SURGICAL, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 SEA MOUNTAIN HWY SUITE A
LITTLE RIVER SC
29566-8161
US

IV. Provider business mailing address

PO BOX 599
LORIS SC
29569-0599
US

V. Phone/Fax

Practice location:
  • Phone: 843-399-9774
  • Fax: 843-399-8657
Mailing address:
  • Phone: 843-399-9774
  • Fax: 843-399-8657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MS. WILMA F POND
Title or Position: OFFICE MANAGER
Credential:
Phone: 843-399-9774