Provider Demographics
NPI:1215011184
Name:SOUTH, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SOUTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 WHITE POND DR STE B
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320-1178
Mailing Address - Country:US
Mailing Address - Phone:234-205-2040
Mailing Address - Fax:
Practice Address - Street 1:809 WHITE POND DR STE B
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-1178
Practice Address - Country:US
Practice Address - Phone:234-205-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-091391207V00000X
OH35 091391207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100056360Medicaid
OH2859812Medicaid
NC5901063Medicaid
IN200911640Medicaid
OHH039790Medicare PIN
NC2041317Medicare PIN
NC5901063Medicaid