Provider Demographics
NPI:1013311976
Name:SOUTH POINT HEALTHCARE PC
Entity Type:Organization
Organization Name:SOUTH POINT HEALTHCARE PC
Other - Org Name:SOUTH POINT DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:JERNIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-881-8558
Mailing Address - Street 1:13615 WOODBROOK DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3165
Mailing Address - Country:US
Mailing Address - Phone:678-357-6030
Mailing Address - Fax:
Practice Address - Street 1:613 THOMPSON AVE
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4557
Practice Address - Country:US
Practice Address - Phone:870-881-8558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-21
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty