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General NPI Number Information
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NPI Number | 1801991849
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Entity Type | Organization
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Legal Business Name | SOUTHERN SURGERY SPECIALISTS, LLC
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Dates
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Enumeration Date | 09/14/2006
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Last Update Date | 11/07/2008
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Provider Practice Location Address
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Address Line | 408 JACKSON AVE E
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City | HAMPTON
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State | SC
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Zip | 29924
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Country | US
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Telephone | 803-943-4003
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Fax | 803-943-4701
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Provider Business Mailing Address
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Address Line | PO BOX 1289
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City | VARNVILLE
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State | SC
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Zip | 29944
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Country | US
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Telephone | 803-943-4003
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Fax | 803-943-4701
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CARLOS E MONTENEGRO
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Credential | MD
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Telephone | 803-943-4003
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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 | 23479
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License Number State | SC
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