Provider Demographics
NPI:1376659870
Name:SOUTHERN GASTROENTEROLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:SOUTHERN GASTROENTEROLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-572-8196
Mailing Address - Street 1:1129 N MAIN ST STE G
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-2547
Mailing Address - Country:US
Mailing Address - Phone:434-572-8196
Mailing Address - Fax:434-572-8341
Practice Address - Street 1:1129 N MAIN ST STE G
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-2547
Practice Address - Country:US
Practice Address - Phone:434-572-8196
Practice Address - Fax:434-572-8341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty