NPIMap

Organization Active NPI

Beavercreek Medical Center

Doing business as Kettering Health Primary Care, A Service of Soin 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
Doing business as
Kettering Health Primary Care, A Service of Soin Medical Center
Practice address
1500 Rombach Ave
Wilmington, OH 45177-2080
Phone
(937) 382-0918
NPI assigned
Jun 30, 2022
Last updated
Aug 11, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
BEAVERCREEK MEDICAL CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 11, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

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

Specialties & licenses 1

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

Addresses

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

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

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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1558093286. Details of each certification follow.

Rural health clinic certification: CCN 363438

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

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

Other NPIs with the same Medicare PAC ID 1

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

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

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

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

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

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

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

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

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

Ownership & related parties

All disclosed owners & managing parties 13

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

Owners & managing parties with NPI records 4

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

Facilities with the same owner 11

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

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "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.