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General NPI Number Information
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NPI Number | 1891083135
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Entity Type | Organization
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Legal Business Name | SOUTHERN PRIMARY CARE PLLC
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Dates
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Enumeration Date | 07/20/2011
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Last Update Date | 07/20/2011
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Provider Practice Location Address
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Address Line | 511 BROOKMAN DR
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City | BROOKHAVEN
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State | MS
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Zip | 39601-2326
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Country | US
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Telephone | 601-833-3800
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Fax | 601-833-3847
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Provider Business Mailing Address
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Address Line | 511 BROOKMAN DR
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City | BROOKHAVEN
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State | MS
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Zip | 39601-2326
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Country | US
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Telephone | 601-833-3800
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Fax | 601-833-3847
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | ROBERT K WALKER
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Credential | MD
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Telephone | 601-833-3800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State | MS
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