=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063412450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TILTONSVILLE CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 342 JEFFERSON ST
-----------------------------------------------------
City | TILTONSVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43963-1058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-859-2121
-----------------------------------------------------
Fax | 740-859-2443
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 342 JEFFERSON ST
-----------------------------------------------------
City | TILTONSVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43963-1058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-859-2121
-----------------------------------------------------
Fax | 740-859-2443
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OWNER
-----------------------------------------------------
Name | DOUGLAS SCOTT TRUBIANO
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 740-859-2121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 34007831T
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------