Basic Information
| Provider Information | |||||||||
| NPI: | 1467405225 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLYO INTERNAL MEDICINE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7073 CLYO RD | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454594816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374355857 | ||||||||
| FaxNumber: | 9379124960 | ||||||||
| Practice Location | |||||||||
| Address1: | 7073 CLYO RD | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454594816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374355857 | ||||||||
| FaxNumber: | 9379124960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PALMER | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9374355857 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207QG0300X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 363A00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2591673 | 05 | OH | MEDICAID |