Provider Demographics
NPI:1801976311
Name:SOUTHLAND FAMILY MEDICINE ASSOCIATES INC
Entity type:Organization
Organization Name:SOUTHLAND FAMILY MEDICINE ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:J
Authorized Official - Last Name:STEGALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-629-2772
Mailing Address - Street 1:03920 SOUTHLAND RD PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:NEW BREMEN
Mailing Address - State:OH
Mailing Address - Zip Code:45869
Mailing Address - Country:US
Mailing Address - Phone:419-629-2772
Mailing Address - Fax:419-629-3613
Practice Address - Street 1:03920 SOUTHLAND RD
Practice Address - Street 2:
Practice Address - City:NEW BREMEN
Practice Address - State:OH
Practice Address - Zip Code:45869
Practice Address - Country:US
Practice Address - Phone:419-629-2772
Practice Address - Fax:419-629-3613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 04 8500 L207Q00000X
OH35 02 4908 B207Q00000X
OH35 03 2392 S207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0995811Medicaid
OH0995811Medicaid