Provider Demographics
NPI:1043739196
Name:SOUTHERN OHIO RECOVERY GROUP, INC
Entity Type:Organization
Organization Name:SOUTHERN OHIO RECOVERY GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RACHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-377-9374
Mailing Address - Street 1:9403 KENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-6895
Mailing Address - Country:US
Mailing Address - Phone:513-543-6600
Mailing Address - Fax:
Practice Address - Street 1:9403 KENWOOD RD
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-6895
Practice Address - Country:US
Practice Address - Phone:513-543-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH31094333Medicaid