Provider Demographics
NPI:1871557397
Name:GREAT SOUTH MEDICAL INC.
Entity type:Organization
Organization Name:GREAT SOUTH MEDICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:F
Authorized Official - Last Name:LOUVIERE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-664-8874
Mailing Address - Street 1:382 CARRIAGE HOUSE DR STE A
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2299
Mailing Address - Country:US
Mailing Address - Phone:731-664-8716
Mailing Address - Fax:731-664-8932
Practice Address - Street 1:382 CARRIAGE HOUSE DR STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2299
Practice Address - Country:US
Practice Address - Phone:731-664-8716
Practice Address - Fax:731-664-8932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000507332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0183977OtherBCBS TN
B1203OtherBCBS LA
0183977OtherBCBS TN