Basic Information
| Provider Information | |||||||||
| NPI: | 1467090670 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KETTERING MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KETTERING HEALTH NETWORK PREBLE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2110 LEITER RD | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373844506 | ||||||||
| FaxNumber: | 9375227685 | ||||||||
| Practice Location | |||||||||
| Address1: | 450B WASHINGTON JACKSON RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | EATON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453207601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374568340 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2019 | ||||||||
| LastUpdateDate: | 04/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOTELLING | ||||||||
| AuthorizedOfficialFirstName: | DANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9377621644 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KETTERING MEDICAL CENTER | ||||||||
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| NPICertificationDate: | 04/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.