1629387865 NPI number — KETTERING INDEPENDENT MEDICAL GROUP INC

Table of content: (NPI 1629387865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629387865 NPI number — KETTERING INDEPENDENT MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KETTERING INDEPENDENT MEDICAL GROUP INC
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 SPECIALTY CARE, INC.
Provider Other Organization Name Type Code:
4
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:
1629387865
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 PRESTIGE PL STE 550
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMISBURG
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45342-6115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-762-1310
Provider Business Mailing Address Fax Number:
937-522-8068

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 PRESTIGE PL
Provider Second Line Business Practice Location Address:
SUITE 910
Provider Business Practice Location Address City Name:
MIAMISBURG
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45342-3794
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-762-1629
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/06/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KO
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
Y
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
937-395-8522

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0207472 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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