Basic Information
| Provider Information | |||||||||
| NPI: | 1801038807 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN OHIO EMERGENCY PHYSICIANS LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 REMIT DRIVE | ||||||||
| Address2: | SUITE 1122 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606751122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669165259 | ||||||||
| FaxNumber: | 2319224030 | ||||||||
| Practice Location | |||||||||
| Address1: | 1430 COLUMBUS AVE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON COURT HOUSE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431601703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403351210 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2009 | ||||||||
| LastUpdateDate: | 07/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | DERIK | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | LLP MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8669165259 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2947048 | 05 | OH | MEDICAID |