Basic Information
Provider Information | |||||||||
NPI: | 1326142480 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEALTHSOURCE OF OHIO, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HEALTHSOURCE: HILLSBORO HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 424 WARDS CORNER RD STE 200 | ||||||||
Address2: |   | ||||||||
City: | LOVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 451406966 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5137074041 | ||||||||
FaxNumber: | 5135761020 | ||||||||
Practice Location | |||||||||
Address1: | 1108 NORTHVIEW DRIVE | ||||||||
Address2: | SUITE 1 | ||||||||
City: | HILLSBORO | ||||||||
State: | OH | ||||||||
PostalCode: | 451338591 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9373935781 | ||||||||
FaxNumber: | 9373935784 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/11/2006 | ||||||||
LastUpdateDate: | 09/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PATTON | ||||||||
AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5135767700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
ID | Type | State | Issuer | Description | 2526494 | 05 | OH |   | MEDICAID |