MEDICARE: SOUTHERN INJURY SPECIALISTS 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	208VP0000X	Pain Medicine Physician

General Provider Information

NPI Number	:	1508648445
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN INJURY SPECIALISTS LLC

Provider Business Mailing Address
First Line	:	601 BROAD ST SE STE A
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-3718
Country	:	US
Telephone Number	:	678-971-4167
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 BROAD ST SE STE A
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-3718
Country	:	US
Telephone Number	:	678-971-4167
Fax Number	:	833-989-2501

Authorized Official
Title or Position	:	OWNER
Name	:	ANKUR PATEL
Credential	:	DO
Telephone Number	:	205-422-5189

Provider Enumeration Date	:	10/16/2023
Last Update Date	:	10/17/2023

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