Provider Demographics
NPI:1134484249
Name:SOUTHERN OBSTETRIC & GYNECO ASSOCIATES
Entity Type:Organization
Organization Name:SOUTHERN OBSTETRIC & GYNECO ASSOCIATES
Other - Org Name:SOUTHERN OB/GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:DOLL-POLLARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-526-2209
Mailing Address - Street 1:9447 HOLY CROSS LN
Mailing Address - Street 2:
Mailing Address - City:BREESE
Mailing Address - State:IL
Mailing Address - Zip Code:62230-3510
Mailing Address - Country:US
Mailing Address - Phone:618-526-2209
Mailing Address - Fax:618-526-7372
Practice Address - Street 1:211 E HANOVER ST
Practice Address - Street 2:
Practice Address - City:NEW BADEN
Practice Address - State:IL
Practice Address - Zip Code:62265-1811
Practice Address - Country:US
Practice Address - Phone:618-526-2209
Practice Address - Fax:618-526-7372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100027207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL042005236OtherCORPORATE LICENSE
0994340001Medicare NSC