MEDICARE: SOUTHERN VASCULAR AND PAIN SURGERY CENTER OLIVE BRANCH 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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1063307650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN VASCULAR AND PAIN SURGERY CENTER OLIVE BRANCH LLC

Provider Business Mailing Address
First Line	:	921 DENT RD
Second Line	:
City	:	EADS
State	:	TN
Zip	:	38028-9704
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8990 GERMANTOWN RD STE A
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-8532
Country	:	US
Telephone Number	:	901-350-0678
Fax Number	:

Authorized Official
Title or Position	:	MD/OWNER
Name	:	THOMAS HODGKISS
Credential	:	MD
Telephone Number	:	901-350-0978

Provider Enumeration Date	:	06/12/2025
Last Update Date	:	12/03/2025

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