Provider Demographics
NPI:1881608867
Name:DETHERAGE, JAMES M (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:DETHERAGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:617 23RD ST STE 212
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2880
Practice Address - Country:US
Practice Address - Phone:606-408-8485
Practice Address - Fax:606-408-1351
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35082207207Q00000X
KY35730207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY080180308OtherRR MEDICARE
OH2282462Medicaid
KYP00852998OtherRR MEDICARE
KY64012669Medicaid
KYP400021396Medicare PIN
OH4112813Medicare PIN
KYP00852998OtherRR MEDICARE
G74043Medicare UPIN