Basic Information
| Provider Information | |||||||||
| NPI: | 1447339015 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 S. VETERANS BLVD | ||||||||
| Address2: | |||||||||
| City: | GLENNVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126540475 | ||||||||
| FaxNumber: | 9126540486 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 S. VETERANS BLVD | ||||||||
| Address2: | |||||||||
| City: | GLENNVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126540475 | ||||||||
| FaxNumber: | 9126540486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 02/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | SCOTT | ||||||||
| AuthorizedOfficialFirstName: | JESSE | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9126540465 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 000432 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | 000432 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000766114A | 05 | GA | MEDICAID |