Basic Information
| Provider Information | |||||||||
| NPI: | 1720505621 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEMMINGER | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 612 OHIO AVE | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453732153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192398285 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3095 KETTERING BLVD | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372938300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2017 | ||||||||
| LastUpdateDate: | 08/23/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.1700485 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 910000791640 | 05 | OH | MEDICAID |