Basic Information
| Provider Information | |||||||||
| NPI: | 1215275110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KETSCHKE | ||||||||
| FirstName: | RHETT | ||||||||
| MiddleName: | ARTHUR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8401 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | BOARDMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445126725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406862300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8401 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | BOARDMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445126725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406862300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2013 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | 0102203955 | VA | N | Other Service Providers | Military Health Care Provider | 171000000X | R4411 | TX | N | Other Service Providers | Military Health Care Provider | 208D00000X | 0102203955 | VA | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | R4411 | TX | N | Allopathic & Osteopathic Physicians | General Practice | 207P00000X | 34.014640 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | R4411 | 01 | TX | LICENSE | OTHER | 0102203955 | 01 | VA | LICENSE | OTHER |