Healthcare Provider Details

I. General information

NPI: 1477915056
Provider Name (Legal Business Name): ANNA MARIA SOUTH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST
LEXINGTON KY
40536-0001
US

IV. Provider business mailing address

900 S LIMESTONE CTW 304
LEXINGTON KY
40536-0001
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-9918
  • Fax:
Mailing address:
  • Phone: 859-323-9918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number52839
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number52839
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: