Provider Demographics
NPI:1316358484
Name:SOUTHERN, GRAYSAN KIRK (MD)
Entity Type:Individual
Prefix:
First Name:GRAYSAN
Middle Name:KIRK
Last Name:SOUTHERN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 JESSE HILL JR DR SE RM 410
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3033
Mailing Address - Country:US
Mailing Address - Phone:919-801-0538
Mailing Address - Fax:
Practice Address - Street 1:69 JESSE HILL JR DR SE RM 410
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3033
Practice Address - Country:US
Practice Address - Phone:919-801-0538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMTL002503207V00000X
GA80076207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology