Healthcare Provider Details

I. General information

NPI: 1699846287
Provider Name (Legal Business Name): WRIGHT STATE UNIVERSITY DEPT OF EMERGENCY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 SOUTHERN BLVD KETTERING MEDICAL CENTER
KETTERING OH
45429-1221
US

IV. Provider business mailing address

3881 FELICE CT
BEAVERCREEK OH
45432-2073
US

V. Phone/Fax

Practice location:
  • Phone: 937-395-8839
  • Fax:
Mailing address:
  • Phone: 937-431-5401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2865M2000X
TaxonomyMilitary General Acute Care Hospital
License NumberMD40610
License Number StateTN

VIII. Authorized Official

Name: CINDY LOU HARRIS
Title or Position: RESIDENT, EMERGENCY MEDICINE
Credential: MD
Phone: 937-395-8839