1417978263 NPI number — KEREN RAY DO

Table of content: KEREN RAY DO (NPI 1417978263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417978263 NPI number — KEREN RAY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAY
Provider First Name:
KEREN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417978263
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1149 EXPERIMENT FARM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45373-1071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-914-7179
Provider Business Mailing Address Fax Number:
937-522-9960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4000 MIAMISBURG CENTERVILLE RD
Provider Second Line Business Practice Location Address:
SUITE 450
Provider Business Practice Location Address City Name:
MIAMISBURG
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45342-3908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-439-3600
Provider Business Practice Location Address Fax Number:
937-439-3786
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  34-007950 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 34.007950 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2435878 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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