Provider Demographics
NPI:1063507549
Name:SOUTHERN PHYSICAL MEDICINE AND REHABILITATION ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:SOUTHERN PHYSICAL MEDICINE AND REHABILITATION ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RAHUL
Authorized Official - Middle Name:
Authorized Official - Last Name:VOHRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-420-1930
Mailing Address - Street 1:1020 RIVER OAKS DRIVE
Mailing Address - Street 2:STE 450
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39232
Mailing Address - Country:US
Mailing Address - Phone:601-420-1930
Mailing Address - Fax:601-420-1931
Practice Address - Street 1:1020 RIVER OAKS DRIVE
Practice Address - Street 2:STE 450
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39232
Practice Address - Country:US
Practice Address - Phone:601-420-1930
Practice Address - Fax:601-420-1931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015681Medicaid
MSCH8503OtherRAILROAD MEDICARE
MSC02629Medicare PIN
MS09015681Medicaid