Provider Demographics
NPI:1639326994
Name:SOUTHERN SURGERY CENTER LLC
Entity Type:Organization
Organization Name:SOUTHERN SURGERY CENTER LLC
Other - Org Name:SOUTHERN SURGERY CENTER ANESTHESIA GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:BOM
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-812-9902
Mailing Address - Street 1:1805 VERNON RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-3871
Mailing Address - Country:US
Mailing Address - Phone:706-812-9902
Mailing Address - Fax:706-812-0802
Practice Address - Street 1:1805 VERNON RD
Practice Address - Street 2:SUITE C
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3871
Practice Address - Country:US
Practice Address - Phone:706-812-9902
Practice Address - Fax:706-812-0802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2810Medicare PIN