Provider Demographics
NPI:1053342816
Name:SOUTHERN OHIO MEDICAL CENTER
Entity type:Organization
Organization Name:SOUTHERN OHIO MEDICAL CENTER
Other - Org Name:
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 1:1248 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 1:1805 27TH 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:740-356-5000
Practice Address - Fax:740-353-2951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282N00000X
OH36D0350966291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7892571Medicaid
OH360008Medicare ID - Type Unspecified