MEDICARE: GINA SOUTH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	51391	CO
2	2080H0002X	Pediatric Hospice and Palliative Medicine Physician	4301098173	MI
3	208000000X	Pediatrics Physician	4301098173	MI

General Provider Information

NPI Number	:	1255507596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA SOUTH M.D.

Provider Business Mailing Address
First Line	:	14288 E OLD US HWY 12 STE 100
Second Line	:
City	:	CHELSEA
State	:	MI
Zip	:	48118-2700
Country	:	US
Telephone Number	:	734-475-9175
Fax Number	:

Provider Business Practice Location Address
First Line	:	14288 E OLD US HWY 12 STE 100
Second Line	:
City	:	CHELSEA
State	:	MI
Zip	:	48118-2700
Country	:	US
Telephone Number	:	734-475-9175
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2008
Last Update Date	:	10/12/2023

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Directions to “ GINA SOUTH M.D.” Practice Location

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