Provider Demographics
NPI:1588772776
Name:KETTERING AFFILIATED HEALTH SERVICES
Entity type:Organization
Organization Name:KETTERING AFFILIATED HEALTH SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:KETTERING HEALTH 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:937-558-3223
Mailing Address - Street 1:2110 LEITER RD
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3660
Mailing Address - Country:US
Mailing Address - Phone:937-914-7054
Mailing Address - Fax:937-522-7685
Practice Address - Street 1:2175 LEITER ROAD
Practice Address - Street 2:SYCAMORE GLEN HEALTH CENTER
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342
Practice Address - Country:US
Practice Address - Phone:937-384-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KETTERING AFFILIATED HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-28
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6000314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2244842Medicaid
OH366000Medicare Oscar/Certification