Provider Demographics
NPI:1720037534
Name:KETTERING RADIOLOGIST IMAGING CENTER
Entity Type:Organization
Organization Name:KETTERING RADIOLOGIST IMAGING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:FADELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-439-7861
Mailing Address - Street 1:PO BOX 713082
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-3082
Mailing Address - Country:US
Mailing Address - Phone:614-430-5707
Mailing Address - Fax:
Practice Address - Street 1:540 LINCOLN PARK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-6401
Practice Address - Country:US
Practice Address - Phone:937-439-7861
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000018662OtherANTHEM
OH0604144Medicaid
CK1062OtherMEDICARE RAILROAD
OH0604144Medicaid
000000018662OtherANTHEM