Provider Demographics
NPI:1407288210
Name:HEALTHSOURCE OF OHIO, INC.
Entity Type:Organization
Organization Name:HEALTHSOURCE OF OHIO, INC.
Other - Org Name:HEALTHSOURCE: LEBANON
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 1:1231 COLUMBUS AVE
Practice Address - Street 2:UNIT A 1
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-8195
Practice Address - Country:US
Practice Address - Phone:513-696-4495
Practice Address - Fax:513-228-1236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-02
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0099241Medicaid
OH3618081Medicare PIN