Basic Information
| Provider Information | |||||||||
| NPI: | 1164536611 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN FAMILY MEDICINE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 16312 MOUNT AIRY RD | ||||||||
| Address2: | |||||||||
| City: | SHREWSBURY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173611623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172273800 | ||||||||
| FaxNumber: | 7172273802 | ||||||||
| Practice Location | |||||||||
| Address1: | 16312 MOUNT AIRY RD | ||||||||
| Address2: | |||||||||
| City: | SHREWSBURY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173611623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172273800 | ||||||||
| FaxNumber: | 7172273802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PEDONE | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | BETH | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7172273800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | SO1624336 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 959ASO | 01 | PA | CARE FIRST | OTHER | 50036273 | 01 | PA | CAPITAL BLUE CROSS | OTHER |