Provider Demographics
NPI:1881645828
Name:KETTERING CARD AND VAS SURG
Entity Type:Organization
Organization Name:KETTERING CARD AND VAS SURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPC, CMPE, CSS
Authorized Official - Phone:937-294-3694
Mailing Address - Street 1:3533 SOUTHERN BLVD
Mailing Address - Street 2:STE 5650
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1264
Mailing Address - Country:US
Mailing Address - Phone:937-294-3611
Mailing Address - Fax:937-294-9010
Practice Address - Street 1:3533 SOUTHERN BLVD
Practice Address - Street 2:STE 5650
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1264
Practice Address - Country:US
Practice Address - Phone:937-294-3611
Practice Address - Fax:937-294-9010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0639867Medicaid
OH0639867Medicaid