Provider Demographics
NPI:1669481016
Name:SOUTHERN OHIO GASTROENTEROLOGY INC
Entity Type:Organization
Organization Name:SOUTHERN OHIO GASTROENTEROLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RESHMA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANERJEE-KATARIA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:740-355-8562
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-0428
Mailing Address - Country:US
Mailing Address - Phone:740-355-8562
Mailing Address - Fax:740-355-7149
Practice Address - Street 1:8101 HAYPORT RD
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-1769
Practice Address - Country:US
Practice Address - Phone:740-355-8562
Practice Address - Fax:740-355-7149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008464207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2548881Medicaid
OHI27655Medicare UPIN
OH4155382Medicare ID - Type UnspecifiedMEDICARE