Healthcare Provider Details

I. General information

NPI: 1073523056
Provider Name (Legal Business Name): EDWINA RANDALL ZETTLER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2449 ROSS MILLVILLE RD ROSS MEDICAL CENTER, SUITE 252
HAMILTON OH
45013-8951
US

IV. Provider business mailing address

6259 CASEY CT
FAIRFIELD OH
45014-3694
US

V. Phone/Fax

Practice location:
  • Phone: 888-958-5830
  • Fax: 888-433-6146
Mailing address:
  • Phone: 513-829-7677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35.091084
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number39340
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: