Basic Information
| Provider Information | |||||||||
| NPI: | 1083630693 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KETTERING PODIATRY ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 SOUTHMOOR CIR NE | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454292451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372936896 | ||||||||
| FaxNumber: | 9372939150 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 SOUTHMOOR CIR NE | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454292451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372936896 | ||||||||
| FaxNumber: | 9372939150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 11/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | MALUSKY | ||||||||
| AuthorizedOfficialFirstName: | LANCING | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9372936896 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2748683 | 05 | OH | MEDICAID |