Provider Demographics
NPI:1861628117
Name:SOUTHERN MEDICAL FAMILY CLINIC, INC.
Entity Type:Organization
Organization Name:SOUTHERN MEDICAL FAMILY CLINIC, INC.
Other - Org Name:CARROLLTON MEDICAL &HEALTH CLINIC PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PA
Authorized Official - Middle Name:NOUS
Authorized Official - Last Name:PAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-820-8662
Mailing Address - Street 1:1927 E BELT LINE RD STE 146
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-5814
Mailing Address - Country:US
Mailing Address - Phone:972-820-8662
Mailing Address - Fax:972-820-8664
Practice Address - Street 1:1927 E BELT LINE RD STE 146
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-5814
Practice Address - Country:US
Practice Address - Phone:972-820-8662
Practice Address - Fax:972-820-8664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3680208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty