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General NPI Number Information
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NPI Number | 1376659870
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Entity Type | Organization
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Legal Business Name | SOUTHERN GASTROENTEROLOGY ASSOCIATES PC
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Dates
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Enumeration Date | 08/21/2006
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Last Update Date | 01/07/2022
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Provider Practice Location Address
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Address Line | 1129 N MAIN ST STE G
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City | SOUTH BOSTON
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State | VA
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Zip | 24592-2547
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Country | US
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Telephone | 434-572-8196
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Fax | 434-572-8341
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Provider Business Mailing Address
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Address Line | 1129 N MAIN ST STE G
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City | SOUTH BOSTON
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State | VA
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Zip | 24592-2547
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Country | US
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Telephone | 434-572-8196
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Fax | 434-572-8341
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | NICOLE PALMER
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Credential |
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Telephone | 434-572-8196
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State | VA
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