Basic Information
| Provider Information | |||||||||
| NPI: | 1881608867 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DETHERAGE | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2379 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411052379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064086200 | ||||||||
| FaxNumber: | 6064086612 | ||||||||
| Practice Location | |||||||||
| Address1: | 617 23RD ST STE 212 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411012880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064088485 | ||||||||
| FaxNumber: | 6064081351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35082207 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35730 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080180308 | 01 | KY | RR MEDICARE | OTHER | 2282462 | 05 | OH | MEDICAID | P00852998 | 01 | KY | RR MEDICARE | OTHER | 64012669 | 05 | KY | MEDICAID |