Provider Demographics
NPI:1588864870
Name:CAROLINE H KENNEBECK MD INC
Entity type:Organization
Organization Name:CAROLINE H KENNEBECK MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC. OF CORP.
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SEWAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-435-6222
Mailing Address - Street 1:5701 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2207
Mailing Address - Country:US
Mailing Address - Phone:937-435-6222
Mailing Address - Fax:
Practice Address - Street 1:5701 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2207
Practice Address - Country:US
Practice Address - Phone:937-435-6222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35086104207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCA9356401OtherMEDICARE GROUP ID
OHKE4167291OtherMEDICARE PROVIDER ID
OH2605738Medicaid
OHCA9356401OtherMEDICARE GROUP ID