=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588864870
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROLINE H KENNEBECK MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2007
-----------------------------------------------------
Last Update Date | 07/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5701 FAR HILLS AVE
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45429-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-435-6222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5701 FAR HILLS AVE
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45429-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-435-6222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SEC. OF CORP.
-----------------------------------------------------
Name | MRS. LOIS ANN SEWAK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 937-435-6222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 35086104
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------