Basic Information
| Provider Information | |||||||||
| NPI: | 1336257872 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KETTERING MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KETTERING NETWORK HOMECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1251 E DOROTHY LN | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454192106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372981111 | ||||||||
| FaxNumber: | 9372987210 | ||||||||
| Practice Location | |||||||||
| Address1: | 3535 SOUTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372984331 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 09/12/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KUHN | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CNO/VP OF PATIENT CA | ||||||||
| AuthorizedOfficialTelephone: | 9373958832 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KETTERING MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 1017 (DEPT OF HEALTH | OH | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 0573044 | 05 | OH | MEDICAID |