Provider Demographics
NPI:1164933362
Name:HEALTHSOURCE OF OHIO, INC.
Entity Type:Organization
Organization Name:HEALTHSOURCE OF OHIO, INC.
Other - Org Name:WEST CLERMONT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-576-7700
Mailing Address - Street 1:424 WARDS CORNER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-6966
Mailing Address - Country:US
Mailing Address - Phone:513-707-4041
Mailing Address - Fax:513-576-1020
Practice Address - Street 1:1341 CLOUGH PIKE STE 150
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:OH
Practice Address - Zip Code:45103-2503
Practice Address - Country:US
Practice Address - Phone:513-732-5082
Practice Address - Fax:513-214-2408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-16
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0299023Medicaid