Provider Demographics
NPI:1164535415
Name:GENERAL SURGERY OF SOUTHAVEN LLC
Entity Type:Organization
Organization Name:GENERAL SURGERY OF SOUTHAVEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:FORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-536-1944
Mailing Address - Street 1:401 SOUTHCREST CIR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-6726
Mailing Address - Country:US
Mailing Address - Phone:662-536-1944
Mailing Address - Fax:662-536-1947
Practice Address - Street 1:401 SOUTHCREST CIR
Practice Address - Street 2:SUITE 210
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-6726
Practice Address - Country:US
Practice Address - Phone:662-536-1944
Practice Address - Fax:662-536-1947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03873250Medicaid
MS03873250Medicaid
DF6057Medicare PIN