Basic Information
| Provider Information | |||||||||
| NPI: | 1881645828 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KETTERING CARD AND VAS SURG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3533 SOUTHERN BLVD | ||||||||
| Address2: | STE 5650 | ||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372943611 | ||||||||
| FaxNumber: | 9372949010 | ||||||||
| Practice Location | |||||||||
| Address1: | 3533 SOUTHERN BLVD | ||||||||
| Address2: | STE 5650 | ||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372943611 | ||||||||
| FaxNumber: | 9372949010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 12/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | KRISTINE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9372943694 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPC, CMPE, CSS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 0639867 | 05 | OH | MEDICAID |