1962569749 NPI number — SOUTHERN OHIO NEPHROLOGY, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962569749 NPI number — SOUTHERN OHIO NEPHROLOGY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN OHIO NEPHROLOGY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962569749
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1711 27TH ST
Provider Second Line Business Mailing Address:
BRAUNLIN BLDG. (K) STE 301
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45662-2654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-354-5393
Provider Business Mailing Address Fax Number:
740-353-9068

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1711 27TH ST
Provider Second Line Business Practice Location Address:
BRAUNLIN BLDG. (K) STE 301
Provider Business Practice Location Address City Name:
PORTSMOUTH
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45662-2654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-354-5393
Provider Business Practice Location Address Fax Number:
740-353-9068
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SAMUEL-VARIATH
Authorized Official First Name:
REENA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
740-354-5393

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2222919 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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