Provider Demographics
NPI:1982608691
Name:SOUTHERN FAMILY MEDICINE
Entity Type:Organization
Organization Name:SOUTHERN FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:BEASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-765-9393
Mailing Address - Street 1:606 GERALD MCRANEY ST
Mailing Address - Street 2:
Mailing Address - City:COLLINS
Mailing Address - State:MS
Mailing Address - Zip Code:39428-3801
Mailing Address - Country:US
Mailing Address - Phone:601-765-9393
Mailing Address - Fax:601-765-9363
Practice Address - Street 1:603 S HOLLY AVE
Practice Address - Street 2:
Practice Address - City:COLLINS
Practice Address - State:MS
Practice Address - Zip Code:39428-3801
Practice Address - Country:US
Practice Address - Phone:601-765-9393
Practice Address - Fax:601-765-9363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01588261Medicaid
25D1026870OtherCLIA
25D1026870OtherCLIA