Provider Demographics
NPI:1083630693
Name:KETTERING PODIATRY ASSOCIATES LLC
Entity Type:Organization
Organization Name:KETTERING PODIATRY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCING
Authorized Official - Middle Name:P
Authorized Official - Last Name:MALUSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:937-293-6896
Mailing Address - Street 1:15 SOUTHMOOR CIR NE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2451
Mailing Address - Country:US
Mailing Address - Phone:937-293-6896
Mailing Address - Fax:937-293-9150
Practice Address - Street 1:15 SOUTHMOOR CIR NE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-2451
Practice Address - Country:US
Practice Address - Phone:937-293-6896
Practice Address - Fax:937-293-9150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2748683Medicaid
OH2748683Medicaid
OH5954180001Medicare NSC
9363521Medicare PIN