Provider Demographics
NPI:1336264209
Name:SOUTHMOOR MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:SOUTHMOOR MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:HOCHWALT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-294-4487
Mailing Address - Street 1:38 SOUTHMOOR CIR NE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2443
Mailing Address - Country:US
Mailing Address - Phone:937-294-4487
Mailing Address - Fax:937-294-2255
Practice Address - Street 1:38 SOUTHMOOR CIR NE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-2443
Practice Address - Country:US
Practice Address - Phone:937-294-4487
Practice Address - Fax:937-294-2255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0198772Medicaid
OH9917391Medicare ID - Type Unspecified