| Organization Name: | SOUTHERN HEALTHCARE PROVIDER GROUP, LLC |
| NPI Number: | 1922273747 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | NELSON MEDRANO (CLINIC DIRECTOR) |
| Mailing Address: | 2754 N Decatur Rd Suite 110 Decatur |
| State: | GA US |
| Postal Code: | 300335917 |
| Phone Number: | 4048380082 |
| Fax Number: | |
| NPI Enumeration Date: | 04/23/2008 |
| NPI Last Update Date: | 04/23/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 021447 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | GA |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |