1639530116 NPI number — MARY SOUTH, MD, LLC

Table of content: BARTON JAY TRENTHAM PHD (NPI 1336222579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639530116 NPI number — MARY SOUTH, MD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY SOUTH, MD, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639530116
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
809 WHITE POND DR STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AKRON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44320-1178
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
234-205-2040
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
809 WHITE POND DR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AKRON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44320-1178
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
234-205-2040
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/11/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SOUTH
Authorized Official First Name:
MARY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
234-205-2040

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  35091391 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VF0040X , with the licence number: 35091391 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)