Provider Demographics
NPI:1992956296
Name:KETTERING UROLOGY INSTITUTE INC
Entity type:Organization
Organization Name:KETTERING UROLOGY INSTITUTE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-547-0330
Mailing Address - Street 1:114 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-1902
Mailing Address - Country:US
Mailing Address - Phone:937-547-0330
Mailing Address - Fax:937-547-2575
Practice Address - Street 1:3533 SOUTHERN BLVD
Practice Address - Street 2:STE 5800
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1264
Practice Address - Country:US
Practice Address - Phone:937-438-7682
Practice Address - Fax:937-547-2575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-3367208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35-07-3367OtherLICENSE
OHA39849Medicare UPIN