MEDICARE: SOUTHERNCARE ANESTHETICS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1043908015
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERNCARE ANESTHETICS LLC

Provider Business Mailing Address
First Line	:	4 WILLOW PT STE 50
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-1150
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4 WILLOW PT STE 1B
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-1150
Country	:	US
Telephone Number	:	601-582-6069
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JORY SCOTT
Credential	:
Telephone Number	:	601-582-6069

Provider Enumeration Date	:	04/27/2023
Last Update Date	:	04/27/2023

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