Provider Demographics
NPI:1245216043
Name:SOUTHERN PSYCHIATRIC ASSOCIATES, LLC
Entity Type:Organization
Organization Name:SOUTHERN PSYCHIATRIC ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-978-7800
Mailing Address - Street 1:100 CENTURY PARK SOUTH
Mailing Address - Street 2:SUITE 206
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35226-3922
Mailing Address - Country:US
Mailing Address - Phone:205-978-7800
Mailing Address - Fax:205-978-7802
Practice Address - Street 1:100 CENTURY PARK S
Practice Address - Street 2:SUITE 206
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35226-3949
Practice Address - Country:US
Practice Address - Phone:205-978-7800
Practice Address - Fax:205-978-7802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
51506108Medicare ID - Type Unspecified