Provider Demographics
NPI:1003840927
Name:SOUTHERN SURGICAL & MEDICAL,INC.
Entity Type:Organization
Organization Name:SOUTHERN SURGICAL & MEDICAL,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-519-7224
Mailing Address - Street 1:1220 OLD JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-2120
Mailing Address - Country:US
Mailing Address - Phone:770-954-1186
Mailing Address - Fax:
Practice Address - Street 1:95 PINE GROVE DR
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-2561
Practice Address - Country:US
Practice Address - Phone:404-519-7224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA423450332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies