Provider Demographics
NPI:1104200393
Name:SOUTHERN MEDICAL GROUP, PA
Entity Type:Organization
Organization Name:SOUTHERN MEDICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACULTY STAFF
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:POST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-216-0109
Mailing Address - Street 1:1300 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4646
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4646
Practice Address - Country:US
Practice Address - Phone:850-216-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9231968282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital