Individual
JAMES M DETHERAGE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
617 23RD ST STE 212, ASHLAND, KY 41101-2880
(606) 408-8485
(606) 408-1351
Mailing address
PO BOX 2379, ASHLAND, KY 41105-2379
(606) 408-6200
(606) 408-6612
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
35082207
OH
207Q00000X
Family Medicine Physician
Primary
35730
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
080180308
RR MEDICARE
KY
05
—
2282462
—
OH
05
—
64012669
—
KY
01
—
P00852998
RR MEDICARE
KY
Enumeration date
07/28/2006
Last updated
05/18/2022
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