Provider Demographics
NPI:1659388320
Name:MEDICAL SOUTH FAMILY PRACTICE ASSOC INC
Entity Type:Organization
Organization Name:MEDICAL SOUTH FAMILY PRACTICE ASSOC INC
Other - Org Name:MEDICAL SOUTH FAMILY PRACTICE ASSOC INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-433-0960
Mailing Address - Street 1:330 N MAIN ST
Mailing Address - Street 2:SUITES #101-102
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4465
Mailing Address - Country:US
Mailing Address - Phone:937-433-0960
Mailing Address - Fax:937-433-0958
Practice Address - Street 1:330 N MAIN ST
Practice Address - Street 2:SUITES #101-102
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4465
Practice Address - Country:US
Practice Address - Phone:937-433-0960
Practice Address - Fax:937-433-0958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty