Provider Demographics
NPI:1386044543
Name:SOUTHERN INSTITUTE OF AESTHETICS, PC
Entity type:Organization
Organization Name:SOUTHERN INSTITUTE OF AESTHETICS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOKOUT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:334-699-7546
Mailing Address - Street 1:1733 W MAIN ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1321
Mailing Address - Country:US
Mailing Address - Phone:334-699-7546
Mailing Address - Fax:334-699-7548
Practice Address - Street 1:1733 W MAIN ST
Practice Address - Street 2:SUITE 500
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301
Practice Address - Country:US
Practice Address - Phone:334-699-7546
Practice Address - Fax:334-699-7548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-25
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty