Provider Demographics
NPI:1114196557
Name:SOUTHERN MEDICAL MANAGEMENT, LLC
Entity Type:Organization
Organization Name:SOUTHERN MEDICAL MANAGEMENT, LLC
Other - Org Name:SOUTHERNMED PEDIATRICS HILLCREST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:R.
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:GUYTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-520-5800
Mailing Address - Street 1:2214 OLD CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-9725
Mailing Address - Country:US
Mailing Address - Phone:803-520-9380
Mailing Address - Fax:803-520-5801
Practice Address - Street 1:424 OLD CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-6972
Practice Address - Country:US
Practice Address - Phone:803-520-9380
Practice Address - Fax:803-520-9380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4862Medicaid