Basic Information
| Provider Information | |||||||||
| NPI: | 1508849217 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILEY | ||||||||
| FirstName: | CATHERINE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZOFKIE | ||||||||
| OtherFirstName: | CATHERINE | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3033 KETTERING BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372932133 | ||||||||
| FaxNumber: | 8552522435 | ||||||||
| Practice Location | |||||||||
| Address1: | 3033 KETTERING BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372932133 | ||||||||
| FaxNumber: | 8552522435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 03/24/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 4149 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207Q00000X | 34004149 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | H484060 | 01 | OH | MEDICARE PTAN | OTHER | 0734307 | 05 | OH | MEDICAID |