Provider Demographics
NPI:1780614719
Name:SOUTHERN OHIO MEDICAL CENTER
Entity type:Organization
Organization Name:SOUTHERN OHIO MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:1805 27TH ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2640
Mailing Address - Country:US
Mailing Address - Phone:740-356-7547
Mailing Address - Fax:740-356-6170
Practice Address - Street 1:1805 27TH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2640
Practice Address - Country:US
Practice Address - Phone:740-356-2651
Practice Address - Fax:740-356-2509
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN OHIO MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-04
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0820348Medicaid
OH0820348Medicaid