Provider Demographics
NPI:1760577563
Name:SOUTHERN OHIO OPHTHALMIC ANESTHESIA, LLC
Entity Type:Organization
Organization Name:SOUTHERN OHIO OPHTHALMIC ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:DEMICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-773-6347
Mailing Address - Street 1:159 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-2526
Mailing Address - Country:US
Mailing Address - Phone:740-773-6347
Mailing Address - Fax:740-773-9093
Practice Address - Street 1:159 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-2526
Practice Address - Country:US
Practice Address - Phone:740-773-6347
Practice Address - Fax:740-773-9093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2721040Medicaid
OH2721040Medicaid