MEDICARE: SOUTHERN MEDICAL CONSULTANTS 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	363LP2300X	Primary Care Nurse Practitioner	R733261	MS

General Provider Information

NPI Number	:	1215396577
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN MEDICAL CONSULTANTS LLC

Provider Business Mailing Address
First Line	:	7048 OLD CANTON RD STE 2E
Second Line	:
City	:	RIDGELAND
State	:	MS
Zip	:	39157-1021
Country	:	US
Telephone Number	:	601-992-9790
Fax Number	:	601-992-9796

Provider Business Practice Location Address
First Line	:	7048 OLD CANTON RD STE 2E
Second Line	:
City	:	RIDGELAND
State	:	MS
Zip	:	39157-1021
Country	:	US
Telephone Number	:	601-992-9790
Fax Number	:	601-992-9796

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MICHAEL BERRY
Credential	:
Telephone Number	:	601-927-9355

Provider Enumeration Date	:	02/15/2016
Last Update Date	:	04/18/2025

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