Basic Information
| Provider Information | |||||||||
| NPI: | 1558879965 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN ONCOLOGY SPECIALISTS, PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9930 KINCEY AVE STE 165 | ||||||||
| Address2: | |||||||||
| City: | HUNTERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280786541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049475005 | ||||||||
| FaxNumber: | 8778818455 | ||||||||
| Practice Location | |||||||||
| Address1: | 9930 KINCEY AVE STE 165 | ||||||||
| Address2: | |||||||||
| City: | HUNTERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280786541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049475005 | ||||||||
| FaxNumber: | 8778818455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2018 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7046597848 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | 13089 | NC | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336S0011X | Y | Suppliers | Pharmacy | Specialty Pharmacy |
No ID Information.