Basic Information
| Provider Information | |||||||||
| NPI: | 1992774350 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROUTH | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | RONALD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1915 STARGRASS AVE | ||||||||
| Address2: | |||||||||
| City: | GROVE CITY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431239472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142770953 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 86 COLUMBUS RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457011331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403316910 | ||||||||
| FaxNumber: | 7403316919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34-008410 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2549737 | 05 | OH | MEDICAID |