Provider Demographics
NPI:1407235971
Name:SOUTHERN WOMEN'S HEALTH, PLLC
Entity Type:Organization
Organization Name:SOUTHERN WOMEN'S HEALTH, PLLC
Other - Org Name:WOMEN'S PAVILION OF SOUTH MISSISSIPPI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HOLLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-450-9425
Mailing Address - Street 1:6524 U S HIGHWAY 98
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8569
Mailing Address - Country:US
Mailing Address - Phone:601-268-9393
Mailing Address - Fax:601-268-9559
Practice Address - Street 1:1242 HIGHWAY 29 N
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-8763
Practice Address - Country:US
Practice Address - Phone:601-268-9393
Practice Address - Fax:601-268-9559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-29
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05880376Medicaid