Provider Demographics
NPI:1568660744
Name:SOUTHERN HEALTHCARE PROVIDERS
Entity Type:Organization
Organization Name:SOUTHERN HEALTHCARE PROVIDERS
Other - Org Name:N W MISSISSIPPI SPECIALTY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:C
Authorized Official - Last Name:GIVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-429-1411
Mailing Address - Street 1:PO BOX 18394
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39122-8394
Mailing Address - Country:US
Mailing Address - Phone:770-429-1411
Mailing Address - Fax:770-429-1951
Practice Address - Street 1:1401 RIVER RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-4030
Practice Address - Country:US
Practice Address - Phone:770-429-1411
Practice Address - Fax:770-429-1951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14914170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Single Specialty