NPIMap

Organization Active NPI

Beavercreek Medical Center

  • Rural Health Clinic/Center
  • Wilmington, OH
National Provider Identifier
1558093286
Registry record updated Aug 11, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
BEAVERCREEK MEDICAL CENTER
Practice address
1500 Rombach Ave
Wilmington, OH 45177-2080
Phone
(937) 382-0918
NPI assigned
Jun 30, 2022
Organization subpart
Yes
Parent organization
BEAVERCREEK MEDICAL CENTERAs reported in NPPES

Authorized official

NPPES NPI Registry
Name
Timothy Y Ko
Title
Kettering Health Cfo
Phone
(937) 395-8522

Owners & managing parties with NPI records 4

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Facilities connected through Provider of Services related, parent or unit certification numbers.

Facilities with the same owner 11

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
36D2266541Kettering Health Primary Care, a1500 Rombach Ave, Wilmington, OH 45177Certificate of waiverAug 10, 2026

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OH

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20221205000106 OH Part a Provider - Rural Health Clinic 6608033915 Practice locations: Wilmington, OH

Rural health clinic certification: CCN 363438

Medicare enrollment files
Legal name
BEAVERCREEK MEDICAL CENTER
Doing business as
KETTERING HEALTH PRIMARY CARE, A SERVICE OF SOIN MEDICAL CENTER
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 17, 2023
Last certification
Apr 17, 2023
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Jul 31, 2009 in OH
Enrollment address
1500 Rombach Ave
Wilmington, OH 45177-2080
Related CCNs
360360

All disclosed owners & managing parties 13

Medicare enrollment files

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Roy Chew Individual Corporate DirectorBoard Member May 1, 2022
Delthony Gordon Individual Corporate DirectorBoard Member May 1, 2021
Thomas Peebles Individual Corporate DirectorBoard Member May 1, 2020
Celeste Blyden Individual Corporate DirectorBoard Vice Chair Feb 1, 2023
Philip Parker Individual Corporate DirectorBoard Member May 1, 2020
Michael Mewhirter Individual Corporate OfficerInterim Ceo, Kettering Health Nov 11, 2022
Corporate DirectorBoard Chair May 1, 2021
Daniel Tryon Individual Corporate DirectorPresident Nov 11, 2021
W-2 Managing EmployeePresident Nov 11, 2021
Troy Alan Tyner Individual Corporate DirectorBoard Member May 1, 2021
Timothy Y Ko Individual Corporate OfficerInterim Cfo, Kettering Health Nov 18, 2022
Corporate DirectorTreasurer Oct 1, 2022
Amol Soin Individual Corporate DirectorBoard Member May 1, 2021
Robert Smith Individual Corporate DirectorBoard Member May 1, 2022
Kettering Adventist Healthcare Organization, Kettering, OH Corporation, Non-profit Operational/Managerial Control Jul 31, 2009
Cherish J Prutzman Individual Corporate DirectorBoard Member May 1, 2020

National Provider Directory

National Provider Directory
Tax ID family
Beavercreek Medical Center4 organizations share this tax ID, including this one
Part of
Beavercreek Medical Center

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

3535 Pentagon Blvd
Ste 310
Beavercreek, OH 45431
Phone (937) 702-4050

3535 Pentagon Blvd
Ste 230
Beavercreek, OH 45431
Phone (855) 500-2873

2145 N Fairfield Rd
Ste 110
Beavercreek, OH 45431
Phone (937) 558-3930

3535 Pentagon Blvd
Ste 101
Beavercreek, OH 45431
Phone (937) 702-4000

2100 Emmanuel Way
Ste D
Springfield, OH 45502
Phone (937) 323-2690

2100 Emmanuel Way
Ste C
Springfield, OH 45502
Phone (937) 325-5327

2300 N Limestone St
Ste 110
Springfield, OH 45503
Phone (937) 504-8350

2300 N Limestone St
Ste 100
Springfield, OH 45503
Phone (937) 504-8300

222 W Main St
Wilmington, OH 45177
Phone (937) 382-0918

Specialties & licenses 1

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

NPPES NPI Registry

Primary practice location

1500 Rombach Ave
Wilmington, OH 45177-2080

Mailing address

2110 Leiter Rd
Miamisburg, OH 45342-3598
Phone (937) 298-3399

Other names 1

NPPES NPI Registry
  • Kettering Health Primary Care, A Service of Soin Medical Center Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Aug 11, 2025.

{
    "created_epoch": "1656547200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1754870400000",
    "number": "1558093286",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2110 LEITER RD",
            "city": "MIAMISBURG",
            "state": "OH",
            "postal_code": "453423598",
            "telephone_number": "937-298-3399"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1500 ROMBACH AVE",
            "city": "WILMINGTON",
            "state": "OH",
            "postal_code": "451772080",
            "telephone_number": "937-382-0918"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEAVERCREEK MEDICAL CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "BEAVERCREEK MEDICAL CENTER",
        "enumeration_date": "2022-06-30",
        "last_updated": "2025-08-11",
        "certification_date": "2025-08-11",
        "status": "A",
        "authorized_official_last_name": "KO",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_middle_name": "Y",
        "authorized_official_title_or_position": "KETTERING HEALTH CFO",
        "authorized_official_telephone_number": "937-395-8522"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Kettering Health Primary Care, A Service of Soin Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Wilmington, OH

Sources for this page

Verify at the official NPI Registry.