Provider Demographics
NPI:1952324899
Name:KETTERING MEDICAL CENTER
Entity Type:Organization
Organization Name:KETTERING MEDICAL CENTER
Other - Org Name:KETTERING HEALTH MAIN CAMPUS REHAB UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-395-8522
Mailing Address - Street 1:2110 LEITER RD
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3598
Mailing Address - Country:US
Mailing Address - Phone:937-914-7601
Mailing Address - Fax:937-522-7685
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:KETTERING MEDICAL CENTER
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-298-4331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1017273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4666259Medicaid
OH36T079Medicare Oscar/Certification