Provider Demographics
NPI:1639530116
Name:MARY SOUTH, MD, LLC
Entity Type:Organization
Organization Name:MARY SOUTH, MD, LLC
Other - Org Name:MARY SOUTH, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SOUTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:234-205-2040
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
35091391207V00000X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive SurgeryGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty