Basic Information
| Provider Information | |||||||||
| NPI: | 1639128176 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH COMMUNITY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3095 KETTERING BLVD | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372938300 | ||||||||
| FaxNumber: | 9375341353 | ||||||||
| Practice Location | |||||||||
| Address1: | 3095 KETTERING BLVD | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372938300 | ||||||||
| FaxNumber: | 9375341353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 04/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | SMERZ | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9372938300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 0101 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 0320870 | 05 | OH | MEDICAID | MC34-1000 | 05 | OH | MEDICAID |