1063412450 NPI number — TILTONSVILLE CLINIC, LLC

Table of content: (NPI 1063412450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063412450 NPI number — TILTONSVILLE CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TILTONSVILLE CLINIC, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1063412450
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
342 JEFFERSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TILTONSVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43963-1058
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-859-2121
Provider Business Mailing Address Fax Number:
740-859-2443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
342 JEFFERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TILTONSVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43963-1058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-859-2121
Provider Business Practice Location Address Fax Number:
740-859-2443
Provider Enumeration Date:
07/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TRUBIANO
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
DIRECTOR OWNER
Authorized Official Telephone Number:
740-859-2121

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  34007831T , 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: 000000301650 . This is a "ANTHEM PIN#" identifier . This identifiers is of the category "OTHER".
  • Identifier: HEALTH PLAN OF UPPER . This is a "HMO PIN#" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 7576355 . This is a "AETNA PIN#" identifier . This identifiers is of the category "OTHER".
  • Identifier: 236049386002 . This is a "MED. MUT PIN#" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 224201 . This is a "HEALTH AMERICA/ASSURANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 205446 . This is a "ADVANTRA PIN#" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2346429 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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