Provider Demographics
NPI:1700905593
Name:SOUTHERN SURGICAL PC
Entity Type:Organization
Organization Name:SOUTHERN SURGICAL PC
Other - Org Name:THE VEIN CLINIC AND MEDISPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM (BILL)
Authorized Official - Middle Name:H
Authorized Official - Last Name:MOSES
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:478-275-2454
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31040-0010
Mailing Address - Country:US
Mailing Address - Phone:478-275-2454
Mailing Address - Fax:478-275-0991
Practice Address - Street 1:2406 BELLEVUE RD
Practice Address - Street 2:#11 ERIN OFFICE PARK
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2842
Practice Address - Country:US
Practice Address - Phone:478-275-2454
Practice Address - Fax:478-275-0991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2524982OtherUNITEDHEALTH CARE GROUP #
GA2524982OtherUNITEDHEALTH CARE GROUP #