Provider Demographics
NPI:1083911390
Name:KETTERING INDEPENDENT MEDICAL GROUP INC
Entity Type:Organization
Organization Name:KETTERING INDEPENDENT MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:Y
Authorized Official - Last Name:KO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-558-3223
Mailing Address - Street 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:937-522-8068
Practice Address - Street 1:4000 MIAMISBURG CENTERVILLE RD
Practice Address - Street 2:STE. 230
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-7615
Practice Address - Country:US
Practice Address - Phone:937-384-0790
Practice Address - Fax:937-384-0794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-23
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH614010103OtherFECA
OH614010103OtherFECA