Healthcare Provider Details

I. General information

NPI: 1215971643
Provider Name (Legal Business Name): MILLERSBURG CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5354 TOWNSHIP ROAD 336 STE B
MILLERSBURG OH
44654
US

IV. Provider business mailing address

5354 TOWNSHIP ROAD 336 STE B
MILLERSBURG OH
44654
US

V. Phone/Fax

Practice location:
  • Phone: 330-674-3434
  • Fax: 330-674-3731
Mailing address:
  • Phone: 330-674-3434
  • Fax: 330-674-3731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number350631710
License Number StateOH

VIII. Authorized Official

Name: BUTROS LATOUF
Title or Position: MD
Credential: MD
Phone: 330-674-3434