Basic Information
| Provider Information | |||||||||
| NPI: | 1730293572 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KETTERING MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KETTERING REPRODUCTIVE MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2110 LEITER RD | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372983399 | ||||||||
| FaxNumber: | 9375227685 | ||||||||
| Practice Location | |||||||||
| Address1: | 3533 SOUTHERN BOULEVARD | ||||||||
| Address2: | SUITE 4100 | ||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373958444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 10/27/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | PATTEN | ||||||||
| AuthorizedOfficialFirstName: | CLIFTON | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9373958992 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KETTERING MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0006X | 1017 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Fertility Facility |
No ID Information.