Provider Demographics
NPI:1194292516
Name:SOUTHERN KIDNEY ASSOCIATES PLLC
Entity type:Organization
Organization Name:SOUTHERN KIDNEY ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGOOD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:903-234-9992
Mailing Address - Street 1:3535 N FOURTH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-0037
Mailing Address - Country:US
Mailing Address - Phone:800-276-9017
Mailing Address - Fax:903-234-8287
Practice Address - Street 1:1815 E 70TH ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5301
Practice Address - Country:US
Practice Address - Phone:800-276-9017
Practice Address - Fax:903-234-9992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-24
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty