Provider Demographics
NPI:1790716553
Name:SOUTHERN OHIO MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTHERN OHIO MEDICAL CENTER
Other - Org Name:HOME CARE OF SOUTHERN OHIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-356-8540
Mailing Address - Street 1:1248 KINNEYS LN
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2927
Mailing Address - Country:US
Mailing Address - Phone:740-356-8753
Mailing Address - Fax:740-353-1105
Practice Address - Street 1:724 8TH STREET
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662
Practice Address - Country:US
Practice Address - Phone:740-356-5600
Practice Address - Fax:740-353-5956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0050288Medicaid
OH367087Medicare ID - Type Unspecified