Provider Demographics
NPI:1033537469
Name:OTAIGBE SOUTHERN MEDICAL CARE, PLLC
Entity Type:Organization
Organization Name:OTAIGBE SOUTHERN MEDICAL CARE, PLLC
Other - Org Name:SOUTHERN MEDICAL CARE, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MECHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUCKWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-296-3150
Mailing Address - Street 1:6600 U S HIGHWAY 98
Mailing Address - Street 2:SUITE B
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8441
Mailing Address - Country:US
Mailing Address - Phone:601-261-2727
Mailing Address - Fax:601-261-9847
Practice Address - Street 1:6600 U S HIGHWAY 98
Practice Address - Street 2:SUITE B
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8441
Practice Address - Country:US
Practice Address - Phone:601-261-2727
Practice Address - Fax:601-261-9847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty