Healthcare Provider Details

I. General information

NPI: 1003814526
Provider Name (Legal Business Name): TROY ALAN TYNER D.O.,F.A.C.O.I.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 02/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 COMMONS BLVD SUITE 210
BEAVERCREEK OH
45431-3820
US

IV. Provider business mailing address

2510 COMMONS BLVD SUITE 210
BEAVERCREEK OH
45431-3820
US

V. Phone/Fax

Practice location:
  • Phone: 937-429-0607
  • Fax: 937-558-3067
Mailing address:
  • Phone: 937-429-0607
  • Fax: 937-558-3067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34004819T
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: