Provider Demographics
NPI:1003919176
Name:KETTERING AFFILIATED HEALTH SERVICES
Entity Type:Organization
Organization Name:KETTERING AFFILIATED HEALTH SERVICES
Other - Org Name:KETTERING BREAST EVALUATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:KMC NETWORK CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-395-8816
Mailing Address - Street 1:2110 LEITER RD
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3660
Mailing Address - Country:US
Mailing Address - Phone:937-298-3399
Mailing Address - Fax:937-522-7685
Practice Address - Street 1:580 LINCOLN PARK BOULEVARD, SUITE 200
Practice Address - Street 2:KETTERING BREAST EVALUATION CENTER
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429
Practice Address - Country:US
Practice Address - Phone:937-299-0099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2287412Medicaid
OH2287412Medicaid