Provider Demographics
NPI:1407149800
Name:KETTEL, SETH TYLER (MD)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:TYLER
Last Name:KETTEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 N MAIN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1180
Mailing Address - Country:US
Mailing Address - Phone:937-832-1500
Mailing Address - Fax:
Practice Address - Street 1:9000 N MAIN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45415-1180
Practice Address - Country:US
Practice Address - Phone:937-832-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-18
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.122436207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0099393Medicaid
OH0099393Medicaid