Provider Demographics
NPI:1639369689
Name:SOUTHERN SURGERY WOUND CARE CLINIC PLLC
Entity Type:Organization
Organization Name:SOUTHERN SURGERY WOUND CARE CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DUNCAN
Authorized Official - Last Name:DONALD
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:601-450-2417
Mailing Address - Street 1:139 FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1303
Mailing Address - Country:US
Mailing Address - Phone:601-450-2401
Mailing Address - Fax:601-450-2434
Practice Address - Street 1:139 FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1303
Practice Address - Country:US
Practice Address - Phone:601-450-2401
Practice Address - Fax:601-450-2434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06083556Medicaid
MS512G700120Medicare PIN