Provider Demographics
NPI:1609171255
Name:KETTERING INDEPENDENT MEDICAL GROUP INC
Entity type:Organization
Organization Name:KETTERING INDEPENDENT MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:Y
Authorized Official - Last Name:KO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-558-3223
Mailing Address - Street 1:1 PRESTIGE PL
Mailing Address - Street 2:SUITE 550
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3794
Mailing Address - Country:US
Mailing Address - Phone:937-762-1306
Mailing Address - Fax:937-522-7626
Practice Address - Street 1:113 W NATIONAL RD
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-1934
Practice Address - Country:US
Practice Address - Phone:937-898-5615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-12
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6501360006Medicare NSC
OH=========-88OtherBWC
OH614010107OtherFECA