Provider Demographics
NPI:1568794279
Name:SOUTHERN STAR MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:SOUTHERN STAR MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SIVARAMA
Authorized Official - Middle Name:K
Authorized Official - Last Name:KOTIKALAPUDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-795-4969
Mailing Address - Street 1:PO BOX 4577
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38704-4577
Mailing Address - Country:US
Mailing Address - Phone:662-332-8848
Mailing Address - Fax:
Practice Address - Street 1:67 HIGHPOINTE DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-9536
Practice Address - Country:US
Practice Address - Phone:601-874-5941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18593261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSPENDINGMedicaid
MSI15156Medicare UPIN
MSPENDINGMedicaid