Healthcare Provider Details

I. General information

NPI: 1528050945
Provider Name (Legal Business Name): SOUTHERN OHIO SURGICAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 01/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 27TH ST BRAUNLIN BLDG, SUITE 306
PORTSMOUTH OH
45662-2638
US

IV. Provider business mailing address

1711 27TH ST BRAUNLIN BLDG, SUITE 306
PORTSMOUTH OH
45662-2638
US

V. Phone/Fax

Practice location:
  • Phone: 740-353-8661
  • Fax: 740-354-3254
Mailing address:
  • Phone: 740-353-8661
  • Fax: 740-354-3254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35-06-5158-K
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50-00-1711
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35-84596
License Number StateOH

VIII. Authorized Official

Name: THOMAS L KHOURY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 740-353-8661