Provider Demographics
NPI:1851676696
Name:SOUTHERN PHYSICIANS PLLC
Entity Type:Organization
Organization Name:SOUTHERN PHYSICIANS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:HOSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUSSELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-596-7689
Mailing Address - Street 1:PO BOX 382693
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-2693
Mailing Address - Country:US
Mailing Address - Phone:901-821-0338
Mailing Address - Fax:901-821-0384
Practice Address - Street 1:1265 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3415
Practice Address - Country:US
Practice Address - Phone:901-596-7689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-12
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
103G709059Medicare PIN