Basic Information
| Provider Information | |||||||||
| NPI: | 1972530848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POELSTRA | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3700 SOUTHERN BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376439299 | ||||||||
| FaxNumber: | 9376432343 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 SOUTHERN BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376439299 | ||||||||
| FaxNumber: | 9376432343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 35-054562 | OH | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 06-20069 | 01 | OH | UNITED HEALTHCARE | OTHER | 0641158 | 05 | OH | MEDICAID | 000000019621 | 01 | OH | ANTHEM | OTHER |