MEDICARE: SOUTHERN NEUROSCIENCE CENTER, PA

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	2084N0400X	Neurology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346267325
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN NEUROSCIENCE CENTER, PA

Provider Business Mailing Address
First Line	:	105 ASBURY CIR
Second Line	:	SUITE A
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-1397
Country	:	US
Telephone Number	:	601-268-5222
Fax Number	:	601-296-3508

Provider Business Practice Location Address
First Line	:	105 ASBURY CIR
Second Line	:	SUITE A
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-1397
Country	:	US
Telephone Number	:	601-268-5222
Fax Number	:	601-296-3508

Authorized Official
Title or Position	:	CLINIC ADMINISTRATOR
Name	:	DANNY M. SANFORD
Credential	:
Telephone Number	:	601-268-5222

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	05/20/2008

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