Basic Information
| Provider Information | |||||||||
| NPI: | 1063447167 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORT HAMILTON HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE FORT HAMILTON HOSPITAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2110 LEITER RD | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379147601 | ||||||||
| FaxNumber: | 9375227685 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 EATON AVENUE | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450132767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135858069 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 04/06/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOTELLING | ||||||||
| AuthorizedOfficialFirstName: | DANN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9377621644 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 1117 | OH | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 016142002 | 05 | MO | MEDICAID | 9126813 00 | 05 | FL | MEDICAID | 016142002 | 05 | LA | MEDICAID | 01884633 | 05 | NY | MEDICAID | 01540145 | 05 | KY | MEDICAID | 2875330 | 05 | OH | MEDICAID | 3600132 | 05 | NC | MEDICAID | 372243 | 05 | AZ | MEDICAID | 40 4642389 | 05 | MI | MEDICAID | 431930200 | 05 | ME | MEDICAID | XHSP32617 | 05 | CA | MEDICAID | 154913105 | 05 | AR | MEDICAID | 4181204 | 05 | NJ | MEDICAID | HXSP42617 | 05 | CA | MEDICAID | 000472337X | 05 | GA | MEDICAID | 100275840A | 05 | IN | MEDICAID | 30 4642370 | 05 | MI | MEDICAID |