Provider Demographics
NPI:1013022755
Name:PHYSICIANS SOUTH NEUROLOGY LLC
Entity Type:Organization
Organization Name:PHYSICIANS SOUTH NEUROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:T
Authorized Official - Last Name:DACUNHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-369-5084
Mailing Address - Street 1:740 PRINCE AVE
Mailing Address - Street 2:BLDG #9
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606
Mailing Address - Country:US
Mailing Address - Phone:706-369-5084
Mailing Address - Fax:706-369-5099
Practice Address - Street 1:740 PRINCE AVE
Practice Address - Street 2:BLDG #9
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606
Practice Address - Country:US
Practice Address - Phone:706-369-5084
Practice Address - Fax:706-369-5099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0374352084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA13BDDLWMedicare ID - Type Unspecified
F96100Medicare UPIN