Healthcare Provider Details

I. General information

NPI: 1336264209
Provider Name (Legal Business Name): SOUTHMOOR MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 08/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 SOUTHMOOR CIR NE
KETTERING OH
45429-2443
US

IV. Provider business mailing address

38 SOUTHMOOR CIR NE
KETTERING OH
45429-2443
US

V. Phone/Fax

Practice location:
  • Phone: 937-294-4487
  • Fax: 937-294-2255
Mailing address:
  • Phone: 937-294-4487
  • Fax: 937-294-2255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN JEROME HOCHWALT
Title or Position: PRESIDENT
Credential:
Phone: 937-294-4487