Provider Demographics
NPI:1417513177
Name:SOUTHERN ALLERGY AND MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:SOUTHERN ALLERGY AND MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SASHA
Authorized Official - Middle Name:LASHEA'
Authorized Official - Last Name:BUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-489-5841
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:NEW TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37824-0069
Mailing Address - Country:US
Mailing Address - Phone:423-259-5704
Mailing Address - Fax:423-259-5706
Practice Address - Street 1:109 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37825-6635
Practice Address - Country:US
Practice Address - Phone:423-259-5704
Practice Address - Fax:423-259-5706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty