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General NPI Number Information
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NPI Number | 1760693618
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Entity Type | Organization
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Legal Business Name | SOUTHPORT SURGICAL ASSOCIATES, P.A.
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Dates
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Enumeration Date | 05/24/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 621B N FODALE AVE
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City | SOUTHPORT
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State | NC
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Zip | 28461-3550
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Country | US
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Telephone | 910-457-1880
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Fax |
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Provider Business Mailing Address
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Address Line | 621B N FODALE AVE
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City | SOUTHPORT
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State | NC
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Zip | 28461-3550
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Country | US
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Telephone | 910-457-1880
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LARRY FELIX WEISNER
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Credential |
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Telephone | 910-457-1880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 9400669
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License Number State | NC
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