Provider Demographics
NPI:1275624918
Name:PATRICIA SOUTHWORTH, MD, LLC
Entity Type:Organization
Organization Name:PATRICIA SOUTHWORTH, MD, LLC
Other - Org Name:DR. SOUTHWORTH'S CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SOUTHWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-322-8977
Mailing Address - Street 1:821 N LIMESTONE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-3609
Mailing Address - Country:US
Mailing Address - Phone:937-322-8977
Mailing Address - Fax:937-322-5456
Practice Address - Street 1:821 N LIMESTONE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-3609
Practice Address - Country:US
Practice Address - Phone:937-322-8977
Practice Address - Fax:937-322-5456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020413E207R00000X
OH35.0627542083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH168426305-00OtherBWC PROVIDER NUMBER