Basic Information
| Provider Information | |||||||||
| NPI: | 1336472745 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEARNEY | ||||||||
| FirstName: | RUBY | ||||||||
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| Credential: | PA-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1735 27TH ST STE B06 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456622681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403568681 | ||||||||
| FaxNumber: | 7403537900 | ||||||||
| Practice Location | |||||||||
| Address1: | 8770 OHIO RIVER RD | ||||||||
| Address2: | |||||||||
| City: | WHEELERSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456941918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405749090 | ||||||||
| FaxNumber: | 7403564180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2009 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50.002953RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 50-002953 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 0082605 | 05 | OH | MEDICAID | 7100245620 | 05 | KY | MEDICAID |