Provider Demographics
NPI:1073544508
Name:SOUTHERN MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:SOUTHERN MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:BILLING
Authorized Official - Phone:870-234-5995
Mailing Address - Street 1:211 E STADIUM
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-2032
Mailing Address - Country:US
Mailing Address - Phone:870-234-5995
Mailing Address - Fax:870-234-0278
Practice Address - Street 1:211 E STADIUM
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-2032
Practice Address - Country:US
Practice Address - Phone:870-234-5995
Practice Address - Fax:870-234-0278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty