Provider Demographics
NPI:1376977884
Name:SOUTHERN SURGICAL GROUP, LLC
Entity Type:Organization
Organization Name:SOUTHERN SURGICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:WARD
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-399-9095
Mailing Address - Street 1:3600 SEA MOUNTAIN HWY SUITE A
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566
Mailing Address - Country:US
Mailing Address - Phone:843-399-9095
Mailing Address - Fax:843-399-9098
Practice Address - Street 1:3600 SEA MOUNTAIN HWY SUITE A
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566
Practice Address - Country:US
Practice Address - Phone:843-399-9095
Practice Address - Fax:843-399-9098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC186449174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1891743159OtherNPI