Provider Demographics
NPI:1619398328
Name:SOUTHERN SURGICAL PROVIDERS, P.C.
Entity Type:Organization
Organization Name:SOUTHERN SURGICAL PROVIDERS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:R.
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-754-0382
Mailing Address - Street 1:7120 HODGSON MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-2532
Mailing Address - Country:US
Mailing Address - Phone:912-754-0382
Mailing Address - Fax:912-754-0225
Practice Address - Street 1:459 HIGHWAY 119 S
Practice Address - Street 2:PHYSICIAN CENTER # 2
Practice Address - City:SPRINGFIELD
Practice Address - State:GA
Practice Address - Zip Code:31329-3021
Practice Address - Country:US
Practice Address - Phone:912-352-4490
Practice Address - Fax:912-352-4845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-23
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA56939174400000X
208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty