Provider Demographics
NPI:1801908157
Name:SOUTHERN MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:SOUTHERN MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHIRAG
Authorized Official - Middle Name:R
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-761-1550
Mailing Address - Street 1:1136 CLEVELAND AVE
Mailing Address - Street 2:SUITE 221
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-3618
Mailing Address - Country:US
Mailing Address - Phone:404-761-1550
Mailing Address - Fax:678-233-1633
Practice Address - Street 1:1136 CLEVELAND AVE
Practice Address - Street 2:SUITE 221
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3618
Practice Address - Country:US
Practice Address - Phone:404-761-1550
Practice Address - Fax:678-233-1633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4615Medicare ID - Type Unspecified