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General NPI Number Information
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NPI Number | 1013544899
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Entity Type | Organization
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Legal Business Name | SOUTHERN NEUROLOGY, PHYSICAL MEDICINE & REHABILITATION, LLC
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Dates
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Enumeration Date | 03/24/2020
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Last Update Date | 03/24/2020
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Provider Practice Location Address
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Address Line | 4913 LANES POND RD
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City | VALDOSTA
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State | GA
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Zip | 31601-1537
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Country | US
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Telephone | 229-292-2074
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Fax |
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Provider Business Mailing Address
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Address Line | 4913 LANES POND RD
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City | VALDOSTA
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State | GA
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Zip | 31601-1537
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Country | US
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Telephone | 229-292-2074
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Fax |
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | TOMMY KEITH BUSSEY
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Credential |
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Telephone | 229-292-2074
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number |
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License Number State |
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