Healthcare Provider Details

I. General information

NPI: 1255507596
Provider Name (Legal Business Name): GINA SOUTH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14288 E OLD US HWY 12 STE 100
CHELSEA MI
48118-2700
US

IV. Provider business mailing address

14288 E OLD US HWY 12 STE 100
CHELSEA MI
48118-2700
US

V. Phone/Fax

Practice location:
  • Phone: 734-475-9175
  • Fax:
Mailing address:
  • Phone: 734-475-9175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number51391
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License Number4301098173
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301098173
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: