Provider Demographics
NPI:1871677880
Name:SOUTHERN MEDICAL GROUP
Entity Type:Organization
Organization Name:SOUTHERN MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-654-0475
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:CLAXTON
Mailing Address - State:GA
Mailing Address - Zip Code:30417-0217
Mailing Address - Country:US
Mailing Address - Phone:912-654-0475
Mailing Address - Fax:
Practice Address - Street 1:601 S VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:GLENNVILLE
Practice Address - State:GA
Practice Address - Zip Code:30427-1775
Practice Address - Country:US
Practice Address - Phone:912-654-0475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000461207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300033425AMedicaid
GACI8763OtherRAILROAD MEDICARE
GA300033425AMedicaid