Provider Demographics
NPI:1306084637
Name:VICKSBURG SURGICAL ASSOCIATES, PA
Entity type:Organization
Organization Name:VICKSBURG SURGICAL ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:SUDDERTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-831-2799
Mailing Address - Street 1:188 YMCA PLACE
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-3052
Mailing Address - Country:US
Mailing Address - Phone:601-831-2799
Mailing Address - Fax:601-629-2723
Practice Address - Street 1:188 YMCA PLACE
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-3052
Practice Address - Country:US
Practice Address - Phone:601-831-2799
Practice Address - Fax:601-629-2723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-23
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03081703Medicaid