Organization
SOUTHERN STAR MEDICAL GROUP LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SIVARAMA K KOTIKALAPUDI M.D. (OWNER)
(601) 795-4969
Entity
Organization
Contact information
Practice address
67 HIGHPOINTE DR, HATTIESBURG, MS 39402-9536
(601) 874-5941
Mailing address
PO BOX 4577, GREENVILLE, MS 38704-4577
(662) 332-8848
Taxonomy
Speciality
Code
Description
License number
State
261QH0100X
Health Service Clinic/Center
Primary
18593
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
PENDING
—
MS
Enumeration date
02/04/2010
Last updated
02/04/2010
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