Unknown Individual – Anesthesiology Physician, NPI 1093794190

Anesthesiology Physician

Unknown Individual is a healthcare provider. based in Kettering, Ohio. specializing in Anesthesiology Physician. They hold a License No. 35062738 (OH). The NPI Number for Unknown Individual is 1093794190

Main info

Organization

Inactive

49 Years Of Experience

Accepts Medicare Assignment

Name

Unknown Individual

NPI

1093794190

Phone

(937) 293-8228

Address

3533 SOUTHERN BLVD

Deactivation Date

21 November 2024

Doctor Profile

Medical School Name

LOMA LINDA UNIVERSITY SCHOOL OF MEDICINE

Secondary Phone

9375481141

Graduation Year

1977 (49 years ago)

PAC ID

6608925755

Group Practice PAC ID

0648170365

Professional Enrollment ID

I20090519000554

Data current as of

19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology

Experience14

Completeness75

Years active:0State licenses:1Digital endpointsOther names

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Provider Addresses for Unknown Individual

3533, Southern Boulevard, South Dale, Kettering, Montgomery County, Ohio, 45429, United States
SUITE 3100
KETTERING, OH 454291264
Phone: (937) 293-8228
Fax: (937) 293-8229
Type: Mailing
Kettering Medical Center, 3535, Southern Boulevard, Kettering, Montgomery County, Ohio, 45429, United States
KETTERING, OH 454291221
Phone: (937) 293-8228
Fax: (937) 293-8229
Type: Location

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 45429)

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Provider's Procedures

Unknown Individual performs procedures in Anesthesiology Physician. See the list of HCPCS codes below.

Specialty	Practice State	HCPCS Code	Description	Service Count	Beneficiary Count
ANESTHESIOLOGY	OH	00790	Anesthesia for procedure in upper abdomen including use of an endoscope	22	22

Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.

PAC ID: 0648170365View full group profile

Name	Specialty	State
MISS AUDREY JANE LANDEFELD (MS, CRNA)	-	OH
COURTENAY M DAUMEYER (CRNA)	Certified Registered Nurse Anesthetist (Crna)	OH
DR. REVONNA JOY SMITH (DO)	-	OH
DR. DAVID R GRIGG (M.D.)	-	OH
MICHAEL D WESLEY (CRNA)	-	FL
MR. CHARLES T SHINE (CRNA)	-	OH
MR. CHRISTOPHER KOKE (CRNA)	Certified Registered Nurse Anesthetist (Crna)	NY
CARMEN RENEE SEKULIC (CRNA)	Certified Registered Nurse Anesthetist (Crna)	OH
ANDREA L ARTHUR (CRNA)	-	OH
ANDREW J WOURMS (CRNA)	Certified Registered Nurse Anesthetist (Crna)	OH