Provider Demographics
NPI:1255507596
Name:SOUTH, GINA (MD)
Entity Type:Individual
Prefix:
First Name:GINA
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 1:14288 E OLD US HWY 12 STE 100
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MI
Mailing Address - Zip Code:48118-2700
Mailing Address - Country:US
Mailing Address - Phone:734-475-9175
Mailing Address - Fax:
Practice Address - Street 1:14288 E OLD US HWY 12 STE 100
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118-2700
Practice Address - Country:US
Practice Address - Phone:734-475-9175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO51391208000000X
MI43010981732080H0002X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative Medicine