Provider Demographics
NPI:1912906157
Name:SOUTHERN SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHERN SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURCKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-554-7525
Mailing Address - Street 1:3688 VETERANS MEMORIAL DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-8246
Mailing Address - Country:US
Mailing Address - Phone:601-554-7525
Mailing Address - Fax:601-554-7574
Practice Address - Street 1:3688 VETERANS MEMORIAL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-8246
Practice Address - Country:US
Practice Address - Phone:601-554-7525
Practice Address - Fax:601-554-7574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS015261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770390Medicaid
MS000050871OtherBLUE CROSS & BLUE SHIELD
MS000050871OtherBLUE CROSS & BLUE SHIELD