Provider Demographics
NPI:1841285004
Name:SOUTHERN CARDIOPULMONARY ASSOCIATES PC
Entity type:Organization
Organization Name:SOUTHERN CARDIOPULMONARY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:SIMMOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-884-2641
Mailing Address - Street 1:1551 DOCTORS DR
Mailing Address - Street 2:BUILDING 200
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4139
Mailing Address - Country:US
Mailing Address - Phone:706-884-2641
Mailing Address - Fax:706-884-2353
Practice Address - Street 1:1551 DOCTORS DR
Practice Address - Street 2:BUILDING 200
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4139
Practice Address - Country:US
Practice Address - Phone:706-884-2641
Practice Address - Fax:706-884-2353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300021816AMedicaid
GACB9006OtherRAILROAD MEDICARE
GA300021816AMedicaid