Provider Demographics
NPI:1295033595
Name:STATON SOUTHERN MEDICAL, PLLC
Entity Type:Organization
Organization Name:STATON SOUTHERN MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:D
Authorized Official - Last Name:STATON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-619-6282
Mailing Address - Street 1:131 HOSPITAL DRIVE
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:CARTHAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:131 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 2000
Practice Address - City:CARTHAGE
Practice Address - State:TN
Practice Address - Zip Code:37030
Practice Address - Country:US
Practice Address - Phone:423-364-4817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty