Healthcare Provider Details

I. General information

NPI: 1790755841
Provider Name (Legal Business Name): ANCILLARY SERVICES OF MIDDLETOWN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MCKNIGHT DR
MIDDLETOWN OH
45044-4838
US

IV. Provider business mailing address

PO BOX 632412
CINCINNATI OH
45263-2412
US

V. Phone/Fax

Practice location:
  • Phone: 800-742-2368
  • Fax: 937-291-2962
Mailing address:
  • Phone: 800-742-2368
  • Fax: 937-291-2962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GRACE BROWN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 937-291-7850