Provider Demographics
NPI:1801991849
Name:SOUTHERN SURGERY SPECIALISTS, LLC
Entity type:Organization
Organization Name:SOUTHERN SURGERY SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:E
Authorized Official - Last Name:MONTENEGRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-943-4003
Mailing Address - Street 1:PO BOX 1289
Mailing Address - Street 2:
Mailing Address - City:VARNVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29944
Mailing Address - Country:US
Mailing Address - Phone:803-943-4003
Mailing Address - Fax:803-943-4701
Practice Address - Street 1:408 JACKSON AVE E
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:SC
Practice Address - Zip Code:29924
Practice Address - Country:US
Practice Address - Phone:803-943-4003
Practice Address - Fax:803-943-4701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23479208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC234794Medicaid
1588613103OtherPROVIDER NPI
SC234794Medicaid
H17098Medicare UPIN