Provider Demographics
NPI:1700816774
Name:SOUTHERN OHIO MEDICAL INC
Entity Type:Organization
Organization Name:SOUTHERN OHIO MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SABIR
Authorized Official - Middle Name:M
Authorized Official - Last Name:QURAISHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-587-5435
Mailing Address - Street 1:25800 STATE ROUTE 41
Mailing Address - Street 2:PO BOX 415
Mailing Address - City:PEEBLES
Mailing Address - State:OH
Mailing Address - Zip Code:45660-8953
Mailing Address - Country:US
Mailing Address - Phone:937-587-5435
Mailing Address - Fax:937-587-5437
Practice Address - Street 1:25800 STATE ROUTE 41
Practice Address - Street 2:
Practice Address - City:PEEBLES
Practice Address - State:OH
Practice Address - Zip Code:45660-8953
Practice Address - Country:US
Practice Address - Phone:937-587-5435
Practice Address - Fax:937-587-5437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHG55788Medicare PIN