Provider Demographics
NPI:1609086255
Name:SOUTHERN MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SOUTHERN MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:CLARICE
Authorized Official - Middle Name:D
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-995-7980
Mailing Address - Street 1:1200 CORPORATE DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-2941
Mailing Address - Country:US
Mailing Address - Phone:205-995-7980
Mailing Address - Fax:205-995-7985
Practice Address - Street 1:315 W HICKORY ST
Practice Address - Street 2:
Practice Address - City:SYLACAUGA
Practice Address - State:AL
Practice Address - Zip Code:35150-2913
Practice Address - Country:US
Practice Address - Phone:256-249-5700
Practice Address - Fax:256-249-5029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========OtherTAX ID