1336257872 NPI number — KETTERING MEDICAL CENTER

Table of content: (NPI 1336257872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336257872 NPI number — KETTERING MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KETTERING MEDICAL CENTER
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:
KETTERING NETWORK HOMECARE
Provider Other Organization Name Type Code:
3
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:
1336257872
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1251 E DOROTHY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KETTERING
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45419-2106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-298-1111
Provider Business Mailing Address Fax Number:
937-298-7210

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3535 SOUTHERN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KETTERING
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45429-1221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-298-4331
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KUHN
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
Authorized Official Title or Position:
CNO/VP OF PATIENT CA
Authorized Official Telephone Number:
937-395-8832

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  1017 (DEPT OF HEALTH , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0573044 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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