Basic Information
Provider Information | |||||||||
NPI: | 1053342816 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHERN OHIO MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1248 KINNEYS LN | ||||||||
Address2: |   | ||||||||
City: | PORTSMOUTH | ||||||||
State: | OH | ||||||||
PostalCode: | 456622927 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403568753 | ||||||||
FaxNumber: | 7403531105 | ||||||||
Practice Location | |||||||||
Address1: | 1805 27TH STREET | ||||||||
Address2: |   | ||||||||
City: | PORTSMOUTH | ||||||||
State: | OH | ||||||||
PostalCode: | 45662 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403565000 | ||||||||
FaxNumber: | 7403532951 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2006 | ||||||||
LastUpdateDate: | 12/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WRAY | ||||||||
AuthorizedOfficialFirstName: | DEAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 7403568540 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 36D0350966 | OH | N |   | Laboratories | Clinical Medical Laboratory |   | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 7892571 | 05 | OH |   | MEDICAID |