Provider Demographics
NPI:1760693618
Name:SOUTHPORT SURGICAL ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:SOUTHPORT SURGICAL ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:FELIX
Authorized Official - Last Name:WEISNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-457-1880
Mailing Address - Street 1:621B N FODALE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-3550
Mailing Address - Country:US
Mailing Address - Phone:910-457-1880
Mailing Address - Fax:
Practice Address - Street 1:621B N FODALE AVE
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-3550
Practice Address - Country:US
Practice Address - Phone:910-457-1880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400669208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790156QMedicaid
NC790156QMedicaid
NCF79657Medicare UPIN