Provider Demographics
NPI:1063412450
Name:TILTONSVILLE CLINIC, LLC
Entity type:Organization
Organization Name:TILTONSVILLE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:TRUBIANO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:740-859-2121
Mailing Address - Street 1:342 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:TILTONSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43963-1058
Mailing Address - Country:US
Mailing Address - Phone:740-859-2121
Mailing Address - Fax:740-859-2443
Practice Address - Street 1:342 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:TILTONSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43963-1058
Practice Address - Country:US
Practice Address - Phone:740-859-2121
Practice Address - Fax:740-859-2443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007831T207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000301650OtherANTHEM PIN#
OHHEALTH PLAN OF UPPEROtherHMO PIN#
7576355OtherAETNA PIN#
OH236049386002OtherMED. MUT PIN#
224201OtherHEALTH AMERICA/ASSURANCE
205446OtherADVANTRA PIN#
OH2346429Medicaid
224201OtherHEALTH AMERICA/ASSURANCE
OH9337271Medicare ID - Type UnspecifiedMEDICARE PROVIDER#