NPIMap

Organization Active NPI

Southern Physician Group Management LLC

  • Internal Medicine Physician
  • Nacogdoches, TX
National Provider Identifier
1770162695
Registry record updated Jul 26, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
SOUTHERN PHYSICIAN GROUP MANAGEMENT LLC
Practice address
1204 N Mound St
Nacogdoches, TX 75961-4027
Phone
(936) 564-4611
NPI assigned
Apr 7, 2021
Last updated
Jul 26, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 26, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Grant Douglass
Title
President
Phone
(361) 729-0646

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Emergency Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207P00000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X Primary

Addresses

Primary practice location

1204 N Mound St
Nacogdoches, TX 75961-4027

Mailing address

PO Box 200039
Dallas, TX 75320-0039

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210506002594 TX Part B Supplier - Clinic/Group Practice 6103235973 Receives reassigned benefits from 47 practitioners
Practice locations: Breckenridge, TX; Carrizo Springs, TX; Eagle Pass, TX; Nacogdoches, TX

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 47

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 47

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1617753600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658793600000",
    "number": "1770162695",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 200039",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "753200039"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1204 N MOUND ST",
            "city": "NACOGDOCHES",
            "state": "TX",
            "postal_code": "759614027",
            "telephone_number": "936-564-4611"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN PHYSICIAN GROUP MANAGEMENT LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-04-07",
        "last_updated": "2022-07-26",
        "certification_date": "2022-07-26",
        "status": "A",
        "authorized_official_last_name": "DOUGLASS",
        "authorized_official_first_name": "GRANT",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "361-729-0646"
    },
    "taxonomies": [
        {
            "code": "207P00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Emergency Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Nacogdoches, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 26, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.