Provider Demographics
NPI:1528050945
Name:SOUTHERN OHIO SURGICAL ASSOCIATES, INC.
Entity type:Organization
Organization Name:SOUTHERN OHIO SURGICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:KHOURY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-353-8661
Mailing Address - Street 1:1711 27TH ST
Mailing Address - Street 2:BRAUNLIN BLDG, SUITE 306
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2638
Mailing Address - Country:US
Mailing Address - Phone:740-353-8661
Mailing Address - Fax:740-354-3254
Practice Address - Street 1:1711 27TH ST
Practice Address - Street 2:BRAUNLIN BLDG, SUITE 306
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2638
Practice Address - Country:US
Practice Address - Phone:740-353-8661
Practice Address - Fax:740-354-3254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-5158-K208600000X
OH50-00-1711363AS0400X
OH35-84596208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0317875Medicaid
KY65907073Medicaid
OH0317875Medicaid