Provider Demographics
NPI:1982426243
Name:SOUTHERN SPECIALTY CLINIC, LLC
Entity type:Organization
Organization Name:SOUTHERN SPECIALTY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-985-8296
Mailing Address - Street 1:803 LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9000
Mailing Address - Country:US
Mailing Address - Phone:601-714-1967
Mailing Address - Fax:601-714-1966
Practice Address - Street 1:803 LIBERTY RD
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9000
Practice Address - Country:US
Practice Address - Phone:601-714-1967
Practice Address - Fax:601-714-1966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-28
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-OncologyGroup - Multi-Specialty
No2080B0002XAllopathic & Osteopathic PhysiciansPediatricsObesity MedicineGroup - Multi-Specialty
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty