Basic Information
| Provider Information | |||||||||
| NPI: | 1407288210 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHSOURCE OF OHIO, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALTHSOURCE: LEBANON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 1231 COLUMBUS AVE | ||||||||
| Address2: | UNIT A 1 | ||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450368195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136964495 | ||||||||
| FaxNumber: | 5132281236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2013 | ||||||||
| LastUpdateDate: | 04/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | PATTON | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5135767700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0099241 | 05 | OH | MEDICAID |