Basic Information
| Provider Information | |||||||||
| NPI: | 1023419736 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN SURGICAL SPECIALTIES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1135 | ||||||||
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| City: | CORDELE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310101135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292762004 | ||||||||
| FaxNumber: | 2292763641 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 E 3RD AVE | ||||||||
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| City: | CORDELE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310153208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292714620 | ||||||||
| FaxNumber: | 2292714614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2014 | ||||||||
| LastUpdateDate: | 01/30/2015 | ||||||||
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| AuthorizedOfficialLastName: | CULPEPPER | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | SURGEON | ||||||||
| AuthorizedOfficialTelephone: | 2299384931 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 046072 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.