Provider Demographics
NPI:1346686144
Name:KETTERING SPORTS MEDICINE
Entity Type:Organization
Organization Name:KETTERING SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-395-3900
Mailing Address - Street 1:25 S TIPPECANOE DR
Mailing Address - Street 2:
Mailing Address - City:TIPP CITY
Mailing Address - State:OH
Mailing Address - Zip Code:45371-1167
Mailing Address - Country:US
Mailing Address - Phone:937-669-5757
Mailing Address - Fax:937-669-1270
Practice Address - Street 1:25 S TIPPECANOE DR
Practice Address - Street 2:
Practice Address - City:TIPP CITY
Practice Address - State:OH
Practice Address - Zip Code:45371-1167
Practice Address - Country:US
Practice Address - Phone:937-669-5757
Practice Address - Fax:937-669-1270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT 009747282N00000X
OHAT 001770282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital