Provider Demographics
NPI:1174521645
Name:SOUTHWEST OHIO OB/GYN INC
Entity type:Organization
Organization Name:SOUTHWEST OHIO OB/GYN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:RUSTERHOLZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-424-1654
Mailing Address - Street 1:20 S BREIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-5155
Mailing Address - Country:US
Mailing Address - Phone:513-424-1654
Mailing Address - Fax:513-424-8205
Practice Address - Street 1:20 S BREIEL BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-5155
Practice Address - Country:US
Practice Address - Phone:513-424-1654
Practice Address - Fax:513-424-8205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400375207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0166976Medicaid
GY9244981Medicare ID - Type Unspecified
OHS09244981Medicare UPIN